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Franca Gois PH, Saunderson RB, Wainstein M, Li CK, Damasiewicz MJ, Miao VY, Wolley M, Hepburn K, Mutatiri C, Chacko B, Bonner A, Healy H. Protocol for a hybrid effectiveness-implementation clinical trial evaluating video-assisted electronic consent vs standard consent for patients initiating and continuing haemodialysis in Australia (eConsent HD). BMJ Open 2024; 14:e081181. [PMID: 38991670 PMCID: PMC11243118 DOI: 10.1136/bmjopen-2023-081181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 05/28/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION Communicating complex information about haemodialysis (HD) and ensuring it is well understood remains a challenge for clinicians. Informed consent is a high-impact checkpoint in augmenting patients' decision awareness and engagement prior to HD. The aims of this study are to (1) develop a digital information interface to better equip patients in the decision-making process to undergo HD; (2) evaluate the effectiveness of the co-designed digital information interface to improve patient outcomes; and (3) evaluate an implementation strategy. METHODS AND ANALYSIS First, a co-design process involving consumers and clinicians to develop audio-visual content for an innovative digital platform. Next a two-armed, open-label, multicentre, randomised controlled trial will compare the digital interface to the current informed consent practice among adult HD patients (n=244). Participants will be randomly assigned to either the intervention or control group. Intervention group: Participants will be coached to an online platform that delivers a simple-to-understand animation and knowledge test questions prior to signing an electronic consent form. CONTROL GROUP Participants will be consented conventionally by a clinician and sign a paper consent form. Primary outcome is decision regret, with secondary outcomes including patient-reported experience, comprehension, anxiety, satisfaction, adherence to renal care, dialysis withdrawal, consent time and qualitative feedback. Implementation of eConsent for HD will be evaluated concurrently using the Consolidation Framework for Implementation Research (CFIR) methodology. ANALYSIS For the randomised controlled trial, data will be analysed using intention-to-treat statistical methods. Descriptive statistics and CFIR-based analyses will inform implementation evaluation. ETHICS AND DISSEMINATION Human Research Ethics approval has been secured (Metro North Health Human Research Ethics Committee B, HREC/2022/MNHB/86890), and Dissemination will occur through partnerships with stakeholder and consumer groups, scientific meetings, publications and social media releases. TRIAL REGISTRATION NUMBER Australian and New Zealand Clinical Trials Registry (ACTRN12622001354774).
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Affiliation(s)
- Pedro Henrique Franca Gois
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- The University of Queensland, Brisbane, Queensland, Australia
| | | | | | - Chenlei Kelly Li
- Department of Renal Medicine, Saint George Hospital, Kogarah, New South Wales, Australia
| | | | - Vera Y Miao
- The University of Sydney, Sydney, New South Wales, Australia
| | - Martin Wolley
- The University of Queensland, Brisbane, Queensland, Australia
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Kirsten Hepburn
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Clyson Mutatiri
- Renal Medicine, Wide Bay Hospital and Health Service, Bundaberg, Queensland, Australia
| | - Bobby Chacko
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- The University of Newcastle, Callaghan, New South Wales, Australia
| | - Ann Bonner
- Nursing, Griffith University, Southport, Queensland, Australia
| | - Helen Healy
- The University of Queensland, Brisbane, Queensland, Australia
- Metro North Hospital and Health Service, Herston, Queensland, Australia
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El-Magd ES, Schouten RW, Nadort E, Shaw PKC, Smets YFC, Vleming LJ, Dekker FW, Broekman BFP, Honig A, Siegert CEH. Dialysis withdrawal and symptoms of anxiety and depression: a prospective cohort study. BMC Nephrol 2023; 24:219. [PMID: 37488483 PMCID: PMC10367409 DOI: 10.1186/s12882-023-03267-2] [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: 10/27/2021] [Accepted: 07/10/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND An important aspect of end-of-life decisions in dialysis patients is elective withdrawal from dialysis therapy. Several studies have shown that clinical factors, such as comorbidity, play a role in dialysis withdrawal. The role of symptoms of anxiety and depression is largely unknown. The. METHODS A prospective multi-center study has been set up to investigate anxiety and depressive symptoms longitudinally in dialysis patients. Anxiety and depressive symptoms were investigated using the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) as baseline. Adverse events, including dialysis withdrawal and mortality were registered during follow-up. Multivariable cox proportional hazard models were used with anxiety and depression as the independent variable and dialysis withdrawal as the outcome variable. Models included age, sex, ethnicity and a set of clinical comorbidities. RESULTS A total of 687 patients were included between 2012 and 2017, with a median follow-up of 3.2 years. A total of 48 patients (7%) withdrew from dialysis therapy, and subsequently deceased. Anxiety and depressive symptoms at baseline showed an association with dialysis withdrawal with hazard ratios of 2.31 (1.09-4.88) for anxiety and 2.56 (1.27-5.15) for depressive symptoms, independent of somatic comorbidities. DISCUSSION Withdrawal from dialysis therapy is associated with anxiety and depressive symptoms. Dialysis patients with more severe depressive and anxiety symptoms were more vulnerable for dialysis withdrawal. Insight in factors that play a role in dialysis withdrawal could aid patients and clinicians making an informed decision and develop clinical guidelines.
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Affiliation(s)
- Essam S El-Magd
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands.
| | - Robbert W Schouten
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands
- Department of Internal Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Els Nadort
- Department of Psychiatry and Medical Psychology, OLVG Hospital, Amsterdam, The Netherlands
| | | | - Yves F C Smets
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands
| | - Louis-Jean Vleming
- Department of Nephrology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Birit F P Broekman
- Department of Psychiatry and Medical Psychology, OLVG Hospital, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Mental Health, Amsterdam, The Netherlands
| | - Adriaan Honig
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Carl E H Siegert
- Department of Nephrology, OLVG Hospital, Amsterdam, The Netherlands
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Toapanta N, Comas J, León Román J, Ramos N, Azancot M, Bestard O, Tort J, Soler MJ. Mortality in elderly patients starting hemodialysis program. Semin Dial 2022. [PMID: 35817409 DOI: 10.1111/sdi.13114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/31/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The incidence of older patients over 80 years old with chronic kidney disease who start hemodialysis (HD) program has been increasing in the last decade. METHODS We aimed to identify risk factors for morbidity and mortality in patients older than 80 years with end-stage renal disease who started HD. We conducted a retrospective observational study of the Catalan Renal registry (RMRC). RESULTS A total of 2833 patients equal or older than 80 years (of 15,137) who started HD between 2002 and 2019 from the RMRC were included in the study. In this group, the first dialysis was performed through an arteriovenous fistula in 44%, percutaneous catheter in 28.2%, and tunneled catheter in 26.6%. Conventional dialysis was used in 65.7% and online HD in 34.3%. The most frequent cause of death was cardiac disease (21.8%), followed by social problems (20.4%) and infections (15.9%). Overall survival in older HD during the first year was 84% versus 91% in younger than 80 years (p < 0.001). Cox regression analysis identified the start of HD in the period 2002-2010, chronic obstructive pulmonary disease (COPD), and the onset of HD through vascular graft depicted as risk factors for first-year mortality after dialysis initiation in patients older than 80 years with end-stage renal disease who started HD. CONCLUSIONS In conclusion, patients older than 80 years who started HD program had higher mortality, especially those who presented exacerbation of kidney disease, those with COPD, and those who started with a vascular graft.
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Affiliation(s)
- Néstor Toapanta
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Jordi Comas
- Catalan Transplantation Organization, Barcelona, Spain
| | - Juan León Román
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Natalia Ramos
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - María Azancot
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Oriol Bestard
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Jaume Tort
- Catalan Transplantation Organization, Barcelona, Spain
| | - María José Soler
- Nephrology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
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Nadeau-Fredette AC, Sukul N, Lambie M, Perl J, Davies S, Johnson DW, Robinson B, Van Biesen W, Kramer A, Jager KJ, Saran R, Pisoni R, Chan CT. Mortality Trends after Transfer from Peritoneal Dialysis to Hemodialysis. Kidney Int Rep 2022; 7:1062-1073. [PMID: 35570995 PMCID: PMC9091783 DOI: 10.1016/j.ekir.2022.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/31/2022] [Accepted: 02/21/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction Transition to hemodialysis (HD) is a common outcome in peritoneal dialysis (PD), but the associated mortality risk is poorly understood. This study sought to identify rates of and risk factors for mortality after transitioning from PD to HD. Methods Patients with incident PD (between 2000 and 2014) who transferred to HD for ≥1 day were identified, using data from Australia and New Zealand Dialysis and Transplantation registry (ANZDATA), Canadian Organ Replacement Register (CORR), Europe Renal Association (ERA) Registry, and the United States Renal Dialysis System (USRDS). Crude mortality rates were calculated for the first 180 days after transfer. Separate multivariable Cox models were built for early (<90 days), medium (90–180 days), and late (>180 days) periods after transfer. Results Overall, 6683, 5847, 21,574, and 80,459 patients were included from ANZDATA, CORR, ERA Registry, and USRDS, respectively. In all registries, crude mortality rate was highest during the first 30 days after a transfer to HD declining thereafter to nadir at 4 to 6 months. Crude mortality rates were lower for patients transferring in the most recent years (than earlier). Older age, PD initiation in earlier cohorts, and longer PD vintage were associated with increased risk of death, with the strongest associations during the first 90 days after transfer and attenuating thereafter. Mortality risk was lower for men than women <90 days after transfer, but higher after 180 days. Conclusion In this multinational study, mortality was highest in the first month after a transfer from PD to HD and risk factors varied by time period after transfer. This study highlights the vulnerability of patients at the time of modality transfer and the need to improve transitions.
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Chen JHC, Lim WH, Howson P. Changing landscape of dialysis withdrawal in patients with kidney failure: Implications for clinical practice. Nephrology (Carlton) 2022; 27:551-565. [PMID: 35201646 PMCID: PMC9315017 DOI: 10.1111/nep.14032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/09/2022] [Accepted: 02/19/2022] [Indexed: 11/29/2022]
Abstract
Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high-income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end-of-life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision-making process (including dialysis withdrawal during the COVID-19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies.
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Affiliation(s)
- Jenny H C Chen
- Faculty of Medicine, University of Wollongong, Wollongong, Australia.,Wollongong Hospital, Wollongong, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Medicine, University of Western Australia, Perth, Australia
| | - Prue Howson
- Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia
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van Oevelen M, Abrahams AC, Bos WJW, Hoekstra T, Hemmelder MH, Ten Dam M, van Buren M. Dialysis withdrawal in The Netherlands between 2000 and 2019: time trends, risk factors and centre variation. Nephrol Dial Transplant 2021; 36:2112-2119. [PMID: 34390576 PMCID: PMC8577625 DOI: 10.1093/ndt/gfab244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Dialysis withdrawal is a common cause of death in dialysis-dependent patients. This study aims to describe dialysis withdrawal practice in The Netherlands, focussing on time trends, risk factors and centre variation. METHODS Data were retrieved from the Dutch registry of kidney replacement therapy patients. All patients who started maintenance dialysis and died in the period 2000-2019 were included. The main outcome was death after dialysis withdrawal; all other causes of death were used for comparison. Time trends were analysed as unadjusted data (proportion per year) and the year of death was included in a multivariable logistic model. Univariable and multivariable analyses were performed to identify factors associated with withdrawal. Centre variation was compared using funnel plots. RESULTS A total of 34 692 patients started dialysis and 18 412 patients died while on dialysis. Dialysis withdrawal was an increasingly common cause of death, increasing from 18.3% in 2000-2004 to 26.8% in 2015-2019. Of all patients withdrawing, 26.1% discontinued treatment within their first year. In multivariable analysis, increasing age, female sex, haemodialysis as a treatment modality and year of death were independent factors associated with death after dialysis withdrawal. Centre variation was large (80.7 and 57.4% within 95% control limits of the funnel plots for 2000-2009 and 2010-2019, respectively), even after adjustment for confounding factors. CONCLUSIONS Treatment withdrawal has become the main cause of death among dialysis-dependent patients in The Netherlands, with large variations between centres. These findings emphasize the need for timely advance care planning and improving the shared decision-making process on choosing dialysis or conservative care.
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Affiliation(s)
- Mathijs van Oevelen
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Tiny Hoekstra
- Dutch Renal Registry (RENINE), Nefrovisie Foundation, Utrecht, The Netherlands.,Department of Nephrology, Amsterdam University Medical Center-Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc H Hemmelder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc Ten Dam
- Dutch Renal Registry (RENINE), Nefrovisie Foundation, Utrecht, The Netherlands.,Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
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Chen JHC, Brown MA, Jose M, Brennan F, Johnson DW, Roberts MA, Wong G, Cheikh Hassan H, Kennard A, Walker R, Davies CE, Boudville N, Borlace M, Hawley C, Lim WH. Temporal changes and risk factors of death from early withdrawal within 12 months of dialysis initiation - a cohort study. Nephrol Dial Transplant 2021; 37:760-769. [PMID: 34175956 PMCID: PMC8951200 DOI: 10.1093/ndt/gfab207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background Mortality risk is high soon after dialysis initiation in patients with kidney failure, and dialysis withdrawal is a major cause of early mortality, attributed to psychosocial or medical reasons. The temporal trends and risk factors associated with cause-specific early dialysis withdrawal within 12 months of dialysis initiation remain uncertain. Methods Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the temporal trends and risk factors associated with mortality attributed to early psychosocial and medical withdrawals in incident adult dialysis patients in Australia between 2005 and 2018 using adjusted competing risk analyses. Results Of 32 274 incident dialysis patients, 3390 (11%) experienced death within 12 months post-dialysis initiation. Of these, 1225 (36%) were attributed to dialysis withdrawal, with 484 (14%) psychosocial withdrawals and 741 (22%) medical withdrawals. These patterns remained unchanged over the past two decades. Factors associated with increased risk of death from early psychosocial and medical withdrawals were older age, dialysis via central venous catheter, late referral and the presence of cerebrovascular disease; obesity and Asian ethnicity were associated with decreased risk. Risk factors associated with early psychosocial withdrawals were underweight and higher socioeconomic status. Presence of peripheral vascular disease, chronic lung disease and cancers were associated with early medical withdrawals. Conclusions Death from dialysis withdrawal accounted for >30% of early deaths in kidney failure patients initiated on dialysis and remained unchanged over the past two decades. Several shared risk factors were observed between mortality attributed to early psychosocial and medical withdrawals.
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Affiliation(s)
- Jenny H C Chen
- School of Medicine, University of Wollongong, Wollongong, Australia
- Depatment of Renal Medicine, Wollongong Hospital, Wollongong, Australia
- Correspondence to: Jenny H.C. Chen; E-mail:
| | - Mark A Brown
- Department of Nephrology, St George Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Matthew Jose
- School of Medicine, The University of Tasmania, Hobart, Australia
- Department of Nephrology, Royal Hobart Hospital, Hobart, Australia
| | - Frank Brennan
- Department of Nephrology, St George Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Brisbane, Australia
| | - Matthew A Roberts
- School of Medicine, Monash University, Melbourne, Australia
- Renal Service, Eastern Health, Melbourne, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Hicham Cheikh Hassan
- School of Medicine, University of Wollongong, Wollongong, Australia
- Depatment of Renal Medicine, Wollongong Hospital, Wollongong, Australia
| | - Alice Kennard
- School of Medicine, Australian National University, Canberra, Australia
- Department of Nephrology, Canberra Hospital, Canberra, Australia
| | - Rachael Walker
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- School of Nursing, Eastern Institute of Technology, Napier, New Zealand
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Neil Boudville
- Medical School, University of Western Australia, Perth, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Monique Borlace
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Brisbane, Australia
| | - Wai H Lim
- Medical School, University of Western Australia, Perth, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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Roberts MJ, Johansen KL, Copeland TP, McCulloch CE, Coufal S, Ku E. Factors Associated with Dialysis Discontinuation Outside of the Acute Care Setting. KIDNEY360 2020; 2:331-335. [PMID: 35373030 PMCID: PMC8740984 DOI: 10.34067/kid.0004312020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/09/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Matthew J. Roberts
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kirsten L. Johansen
- Division of Nephrology, Department of Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, Minnesota
| | - Timothy P. Copeland
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Sarah Coufal
- College of Letters and Science, University of California, Los Angeles, California
| | - Elaine Ku
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California,Department of Epidemiology and Biostatistics, University of California, San Francisco, California,Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, California
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