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Afsar B, Afsar RE, Caliskan Y, Lentine KL. A holistic review of sodium intake in kidney transplant patients: More questions than answers. Transplant Rev (Orlando) 2024; 38:100859. [PMID: 38749098 DOI: 10.1016/j.trre.2024.100859] [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: 04/06/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 06/16/2024]
Abstract
Kidney transplantation (KT) is the best treatment option for end-stage kidney disease (ESKD). Acute rejection rates have decreased drastically in recent years but chronic kidney allograft disease (CKAD) is still an important cause of allograft failure and return to dialysis. Thus, there is unmet need to identify and reverse the cause of CKAD. Additionally, cardiovascular events after KT are still leading causes of morbidity and mortality. One overlooked potential contributor to CKAD and adverse cardiovascular events is increased sodium/salt intake in kidney transplant recipients (KTRs). In general population, the adverse effects of high sodium intake are well known but in KTRs, there is a paucity of evidence despite decades of experience with KT. Limited research showed that sodium intake is high in most KTRs. Moreover, excess sodium intake is associated with elevated blood pressure and albuminuria in some studies involving KTRs. There is also experimental evidence suggesting that increased sodium intake is associated with histologic graft damage. Critical knowledge gaps still remain, including the exact amount of sodium restriction needed in KTRs to optimize outcomes and allograft survival. Additionally, best methods to measure sodium intake and practices to follow-up are not clarified in KTRs. To meet these deficits, prospective long term studies are warranted in KTRs. Moreover, preventive measures must be determined and implemented both at individual and societal levels to achieve sodium restriction in KTRs.
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Affiliation(s)
- Baris Afsar
- Suleyman Demirel University, School of Medicine, Department of Nephrology, 32260, Cunur, Isparta, Türkiye; Saint Louis University, School of Medicine, Division of Nephrology, St. Louis, MO, USA.
| | - Rengin Elsurer Afsar
- Suleyman Demirel University, School of Medicine, Department of Nephrology, 32260, Cunur, Isparta, Türkiye; Saint Louis University, School of Medicine, Division of Nephrology, St. Louis, MO, USA
| | - Yasar Caliskan
- Saint Louis University, School of Medicine, Division of Nephrology, St. Louis, MO, USA
| | - Krista L Lentine
- Saint Louis University, School of Medicine, Division of Nephrology, St. Louis, MO, USA
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2
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Kidambi S, Pan X, Yang C, Liu P, Roberts ML, Li Y, Wang T, Laud PW, Liu Y, Rubens M, Thomas R, Widlansky ME, Beyer AM, Liu Y, Cowley AW, Kotchen TA, Munyura Y, Moosreiner A, Mattson DL, Liang M. Dietary Sodium Restriction Results in Tissue-Specific Changes in DNA Methylation in Humans. Hypertension 2021; 78:434-446. [PMID: 34120454 DOI: 10.1161/hypertensionaha.120.17351] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Srividya Kidambi
- Division of Endocrinology, Department of Medicine (S.K., M.R., R.T., T.A.K., Y.M.), Medical College of Wisconsin, Milwaukee
| | - Xiaoqing Pan
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee.,Department of Mathematics, Shanghai Normal University, China (X.P.)
| | - Chun Yang
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee
| | - Pengyuan Liu
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee.,Sir Run Run Shaw Hospital, Institute of Translational Medicine, Zhejiang University, China (P.L., Yi Liu)
| | - Michelle L Roberts
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee
| | - Yingchuan Li
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee.,Department of Critical Care Medicine, Shanghai JiaoTong University Affiliated Sixth People's Hospital, China (Y. Li)
| | - Tao Wang
- Division of Biostatistics, Institute for Health and Equity (T.W., P.W.L.), Medical College of Wisconsin, Milwaukee
| | - Purushottam W Laud
- Division of Biostatistics, Institute for Health and Equity (T.W., P.W.L.), Medical College of Wisconsin, Milwaukee
| | - Yi Liu
- Sir Run Run Shaw Hospital, Institute of Translational Medicine, Zhejiang University, China (P.L., Yi Liu)
| | - Merrill Rubens
- Division of Endocrinology, Department of Medicine (S.K., M.R., R.T., T.A.K., Y.M.), Medical College of Wisconsin, Milwaukee
| | - Richard Thomas
- Division of Endocrinology, Department of Medicine (S.K., M.R., R.T., T.A.K., Y.M.), Medical College of Wisconsin, Milwaukee
| | - Michael E Widlansky
- Division of Cardiovascular Disease, Department of Medicine (M.E.W., A.M.B.), Medical College of Wisconsin, Milwaukee
| | - Andreas M Beyer
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee.,Division of Cardiovascular Disease, Department of Medicine (M.E.W., A.M.B.), Medical College of Wisconsin, Milwaukee
| | - Yong Liu
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee
| | - Allen W Cowley
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee
| | - Theodore A Kotchen
- Division of Endocrinology, Department of Medicine (S.K., M.R., R.T., T.A.K., Y.M.), Medical College of Wisconsin, Milwaukee
| | - Yannick Munyura
- Division of Endocrinology, Department of Medicine (S.K., M.R., R.T., T.A.K., Y.M.), Medical College of Wisconsin, Milwaukee
| | - Andrea Moosreiner
- Clinical and Translational Science Institute (A.M.), Medical College of Wisconsin, Milwaukee
| | - David L Mattson
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee.,Department of Physiology, Medical College of Georgia, Augusta (D.L.M.)
| | - Mingyu Liang
- Department of Physiology, Center of Systems Molecular Medicine (X.P., C.Y., P.L., M.L.R., Y. Li, A.M.B., Yong Liu, A.W.C., D.L.M., M.L.), Medical College of Wisconsin, Milwaukee
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Abstract
Eating more potassium may reduce blood pressure and the occurrence of other cardiovascular diseases by actions on various systems, including the vasculature, the sympathetic nervous system, systemic metabolism, and body fluid volume. Among these, the kidney plays a major role in the potassium-rich diet-mediated blood pressure reduction. PURPOSE OF REVIEW: To provide an overview of recent discoveries about the mechanisms by which a potassium-rich diet leads to natriuresis. RECENT FINDINGS: Although the distal convoluted tubule (DCT) is a short part of the nephron that reabsorbs salt, via the sodium-chloride cotransporter (NCC), it is highly sensitive to changes in plasma potassium concentration. Activation or inhibition of NCC raises or lowers blood pressure. Recent work suggests that extracellular potassium concentration is sensed by the DCT via intracellular chloride concentration which regulates WNK kinases in the DCT. High-potassium diet targets NCC in the DCT, resulting in natriuresis and fluid volume reduction, which are protective from hypertension and other cardiovascular problems.
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Affiliation(s)
- Xiao-Tong Su
- School of Medicine, Oregon Health and Science University, Portland, OR USA
| | - Chao-Ling Yang
- School of Medicine, Oregon Health and Science University, Portland, OR USA
| | - David H. Ellison
- School of Medicine, Oregon Health and Science University, Portland, OR USA ,Oregon Clinical & Translational Research Institute, SN4N, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA ,Veterans Administration Portland Health Care System, Portland, OR USA
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Boslooper-Meulenbelt K, Patijn O, Battjes-Fries MCE, Haisma H, Pot GK, Navis GJ. Barriers and Facilitators of Fruit and Vegetable Consumption in Renal Transplant Recipients, Family Members and Healthcare Professionals-A Focus Group Study. Nutrients 2019; 11:nu11102427. [PMID: 31614629 PMCID: PMC6835653 DOI: 10.3390/nu11102427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 11/30/2022] Open
Abstract
Low fruit and vegetable consumption is associated with poor outcomes after renal transplantation. Insufficient fruit and vegetable consumption is reported in the majority of renal transplant recipients (RTR). The aim of this study was to identify barriers and facilitators of fruit and vegetable consumption after renal transplantation and explore if certain barriers and facilitators were transplant-related. After purposive sampling, RTR (n = 19), their family members (n = 15) and healthcare professionals (n = 5) from a Dutch transplant center participated in seven focus group discussions (three each for RTR and family members, one with healthcare professionals). Transcripts were analyzed using social cognitive theory as conceptual framework and content analysis was used for identification of themes. Transplant-related barriers and facilitators were described separately. In categorizing barriers and facilitators, four transplant-related themes were identified: transition in diet (accompanied by, e.g., fear or difficulties with new routine), physical health (e.g., recovery of uremic symptoms), medication (e.g., cravings by prednisolone) and competing priorities after transplantation (e.g., social participation activities). Among the generic personal and environmental barriers and facilitators, food literacy and social support were most relevant. In conclusion, transplant-related and generic barriers and facilitators were identified for fruit and vegetable consumption in RTR. The barriers that accompany the dietary transition after renal transplantation may contribute to the generally poorer fruit and vegetable consumption of RTR. These findings can be used for the development of additional nutritional counseling strategies in renal transplant care.
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Affiliation(s)
- Karin Boslooper-Meulenbelt
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, 9700 RB, The Netherlands.
| | - Olga Patijn
- Louis Bolk Insitute, Bunnik, 3981 AJ, The Netherlands.
| | | | - Hinke Haisma
- Population Research Center, Faculty Spatial Sciences, University of Groningen, Groningen, 9747 AD, The Netherlands.
| | - Gerda K Pot
- Louis Bolk Insitute, Bunnik, 3981 AJ, The Netherlands.
| | - Gerjan J Navis
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, 9700 RB, The Netherlands.
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Charnaya O, Moudgil A. Hypertension in the Pediatric Kidney Transplant Recipient. Front Pediatr 2017; 5:86. [PMID: 28507980 PMCID: PMC5410589 DOI: 10.3389/fped.2017.00086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/07/2017] [Indexed: 12/14/2022] Open
Abstract
Hypertension after kidney transplant is a frequent occurrence in pediatric patients. It is a risk factor for graft loss and contributes to the significant burden of cardiovascular disease (CVD) in this population. The etiology of posttransplant hypertension is multifactorial including donor factors, recipient factors, medications, and lifestyle factors similar to those prevalent in the general population. Ambulatory blood pressure monitoring has emerged as the most reliable method for measuring hypertension in pediatric transplant recipients, and many consider it to be essential in the care of these patients. Recent technological advances including measurement of carotid intima-media thickness, pulse wave velocity, and myocardial strain using specked echocardiography and cardiac magnetic resonance imaging have improved our ability to assess CVD burden. Since hypertension remains underrecognized and inadequately treated, an early diagnosis and an appropriate control should be the focus of therapy to help improve patient and graft survival.
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Affiliation(s)
- Olga Charnaya
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
| | - Asha Moudgil
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
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Eisenga MF, Kieneker LM, Soedamah-Muthu SS, van den Berg E, Deetman PE, Navis GJ, Gans RO, Gaillard CA, Bakker SJ, Joosten MM. Urinary potassium excretion, renal ammoniagenesis, and risk of graft failure and mortality in renal transplant recipients. Am J Clin Nutr 2016; 104:1703-1711. [PMID: 27935524 DOI: 10.3945/ajcn.116.134056] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 10/11/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Renal transplant recipients (RTRs) have commonly been urged to limit their potassium intake during renal insufficiency and may adhere to this principle after transplantation. Importantly, in experimental animal models, low dietary potassium intake induces kidney injury through stimulation of ammoniagenesis. In humans, low potassium intake is an established risk factor for high blood pressure. OBJECTIVE We hypothesized that low 24-h urinary potassium excretion [UKV; urinary potassium concentration × volume], the gold standard for assessment of dietary potassium intake, represents a risk factor for graft failure and mortality in RTRs. In secondary analyses, we aimed to investigate whether these associations could be explained by ammoniagenesis, plasma potassium, or blood pressure. DESIGN In a prospective cohort of 705 RTRs, we assessed dietary potassium intake by a single 24-h UKV and food-frequency questionnaires. Cox regression analyses were used to investigate prospective associations with outcome. RESULTS We included 705 stable RTRs (mean ± SD age: 53 ± 13 y; 57% men) at 5.4 y (IQR: 1.9-12.0 y) after transplantation and 253 kidney donors. Mean ± SD UKV was 73 ± 24 mmol/24 h in RTRs compared with 85 ± 25 mmol/24 h in kidney donors. During follow-up for 3.1 y (IQR: 2.7-3.9 y), 45 RTRs developed graft failure and 83 died. RTRs in the lowest sex-specific tertile of UKV (women, <55 mmol/24 h; men, <65 mmol/24 h) had an increased risk of graft failure (HR: 3.70; 95% CI: 1.64, 8.34) and risk of mortality (HR; 2.66; 95% CI: 1.53, 4.61), independent of potential confounders. In causal path analyses, 24-h urinary ammonia excretion, plasma potassium, and blood pressure did not affect these associations. CONCLUSIONS Our results indicate that low UKV is associated with a higher risk of graft failure and mortality in RTRs. Specific attention for adequate potassium intake after transplantation seems warranted. This trial was registered at clinicaltrials.gov as NCT02811835.
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Affiliation(s)
| | | | | | - Else van den Berg
- Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; and
| | | | | | - Reinold Ob Gans
- Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; and
| | | | - Stephan Jl Bakker
- Departments of Nephrology and.,Top Institute Food and Nutrition, Wageningen, Netherlands
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Monfá E, Rodrigo E, Belmar L, Sango C, Moussa F, Ruiz San Millán JC, Piñera C, Fernández-Fresnedo G, Arias M. A high sodium intake reduces antiproteinuric response to renin-angiotensin-aldosterone system blockade in kidney transplant recipients. Nefrologia 2016; 36:545-551. [PMID: 27431273 DOI: 10.1016/j.nefro.2016.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/05/2016] [Accepted: 01/28/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Post-transplant proteinuria is associated with lower graft and patient survival. Renin-angiotensin-aldosterone system blockers are used to reduce proteinuria and improve renal outcome. Although it is known that a high salt intake blunts the antiproteinuric effect of ACEI and ARB drugs in non-transplant patients, this effect has not been studied in kidney transplant recipients. OBJECTIVE To analyse the relationship between sodium intake and the antiproteinuric effect of ACEI/ARB drugs in kidney transplant recipients. METHODS We selected 103 kidney transplant recipients receiving ACEI/ARB drugs for more than 6 months due to proteinuria>1 g/day. Proteinuria was analysed at baseline and at 6 months after starting ACEI/ARB treatment. Salt intake was estimated by urinary sodium to creatinine ratio (uNa/Cr). RESULTS Proteinuria fell to less than 1g/day in 46 patients (44.7%). High uNa/Cr was associated with a smaller proteinuria decrease (r=-0.251, P=.011). The percentage proteinuria reduction was significantly lower in patients in the highest uNa/Cr tertile [63.9% (IQR 47.1%), 60.1% (IQR 55.4%), 38.9% (IQR 85.5%), P=.047]. High uNa/Cr independently relates (OR 2.406 per 100 mEq/g, 95% CI: 1.008-5.745, P=.048) to an antiproteinuric response <50% after renin-angiotensin-aldosterone system blockade. CONCLUSIONS A high salt intake results in a smaller proteinuria decrease in kidney transplant recipients with proteinuria treated with ACEI/ARB drugs.
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Affiliation(s)
- Elena Monfá
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Emilio Rodrigo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España.
| | - Lara Belmar
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Cristina Sango
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Fozi Moussa
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | | | - Celestino Piñera
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Gema Fernández-Fresnedo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
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Aaron KJ, Sanders PW. Role of dietary salt and potassium intake in cardiovascular health and disease: a review of the evidence. Mayo Clin Proc 2013; 88:987-95. [PMID: 24001491 PMCID: PMC3833247 DOI: 10.1016/j.mayocp.2013.06.005] [Citation(s) in RCA: 212] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 05/22/2013] [Accepted: 06/04/2013] [Indexed: 02/07/2023]
Abstract
The objective of this review was to provide a synthesis of the evidence on the effect of dietary salt and potassium intake on population blood pressure, cardiovascular disease, and mortality. Dietary guidelines and recommendations are outlined, current controversies regarding the evidence are discussed, and recommendations are made on the basis of the evidence. Designed search strategies were used to search various databases for available studies. Randomized trials of the effect of dietary salt intake reduction or increased potassium intake on blood pressure, target organ damage, cardiovascular disease, and mortality were included. Fifty-two publications from January 1, 1990, to January 31, 2013, were identified for inclusion. Consideration was given to variations in the search terms used and the spelling of terms so that studies were not overlooked, and search terms took the following general form: (dietary salt or dietary sodium or [synonyms]) and (dietary potassium or [synonyms]) and (blood pressure or hypertension or vascular disease or heart disease or chronic kidney disease or stroke or mortality or [synonyms]). Evidence from these studies demonstrates that high salt intake not only increases blood pressure but also plays a role in endothelial dysfunction, cardiovascular structure and function, albuminuria and kidney disease progression, and cardiovascular morbidity and mortality in the general population. Conversely, dietary potassium intake attenuates these effects, showing a linkage to reduction in stroke rates and cardiovascular disease risk. Various subpopulations, such as overweight and obese individuals and aging adults, exhibit greater sensitivity to the effects of reduced salt intake and may gain the most benefits. A diet that includes modest salt restriction while increasing potassium intake serves as a strategy to prevent or control hypertension and decrease cardiovascular morbidity and mortality. Thus, the body of evidence supports population-wide sodium intake reduction and recommended increases in dietary potassium intake as outlined by current guidelines as an essential public health effort to prevent kidney disease, stroke, and cardiovascular disease.
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Affiliation(s)
- Kristal J. Aaron
- Medicine/Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA 35294-0007
| | - Paul W. Sanders
- Medicine/Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA 35294-0007
- Department of Veterans Affairs Medical Center, Birmingham, AL, USA 35233
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