1
|
Yang L, Tang S, He M, Guo J, Gabriel N, Swabe G, Gellad WF, Essien UR, Saba S, Benjamin EJ, Magnani JW, Hernandez I. COVID-19 pandemic and initiation of treatment for atrial fibrillation: a nationwide analysis of claims data. BMC Cardiovasc Disord 2023; 23:604. [PMID: 38066445 PMCID: PMC10704685 DOI: 10.1186/s12872-023-03614-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic profoundly disrupted the delivery of medical care. It remains unclear whether individuals diagnosed with new onset disease during the pandemic were less likely to initiate treatments after diagnosis. We sought to evaluate changes in the treatment initiation of patients newly diagnosed with atrial fibrillation (AF) after the onset of the COVID-19 pandemic. METHODS In this retrospective cohort study, we identified individuals with incident AF from 01/01/2016-09/30/2021 using Optum's de-identified Clinformatics® Data Mart Database. The primary outcome was initiation of oral anticoagulation (OAC) within 30 days of AF diagnosis. Secondary outcomes included initiation of OAC within 180 days of diagnosis, initiation of warfarin, direct oral anticoagulants (DOACs), rhythm control medications and electrical cardioversion within 30 days of diagnosis. We constructed interrupted time series analyses to examine changes in the outcomes following the onset of the pandemic. RESULTS A total of 573,524 patients (age 73.0 ± 10.9 years) were included in the study. There were no significant changes in the initiation of OAC, DOAC, and rhythm control medications associated with the onset of the pandemic. There was a significant decrease in initiation of electrical cardioversion associated with the onset of the pandemic. The rate of electronic cardioversion within 30 days of diagnosis decreased by 4.9% per 1,000 patients after the onset of the pandemic and decreased by about 35% in April 2020, compared to April 2019, from 5.53% to 3.58%. CONCLUSION The COVID-19 pandemic did not affect the OAC initiation within 30 days of AF diagnosis but was associated with a decline in the provision of procedures for patients newly diagnosed with AF.
Collapse
Affiliation(s)
- Lanting Yang
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Shangbin Tang
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Meiqi He
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Nico Gabriel
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Gretchen Swabe
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Division of General Internal Medicine, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Utibe R Essien
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Center for the Study of Healthcare Innovation, Implementation & Policy, University of California, Greater Los Angeles VA Healthcare System, Los Angeles, Los Angeles, CA, USA
| | - Samir Saba
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Emelia J Benjamin
- Department of Epidemiology, Boston University School of Public Health, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Jared W Magnani
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Inmaculada Hernandez
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA.
| |
Collapse
|
2
|
Mackintosh L, Busby A, Farrington K, Hawkins J, Afuwape S, Bristow P, Silva-Gane MD, Hall N, Harris T, Hudson J, Norton S, Ormandy P, Pearce CJ, Santhakumaran S, Sharma S, Sridharan S, Steenkamp R, Slevin J, Wellsted D, Chilcot J. Impact of the COVID-19 pandemic on services for patients with chronic kidney disease: findings of a national survey of UK kidney centres. BMC Nephrol 2023; 24:356. [PMID: 38049710 PMCID: PMC10696738 DOI: 10.1186/s12882-023-03344-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/21/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Services for patients with kidney disease underwent radical adaptations in response to the COVID-19 pandemic. We undertook an online national survey of UK kidney centres to understand the nature, range, and degree of variation in these changes and to explore factors contributing to differing practice. METHODS The survey was designed by a multidisciplinary team of kidney professionals, service users and researchers. It enquired about centre services and staffing, including psychosocial provision, and changes to these in response to the COVID-19 pandemic. Links to the survey were sent to all 68 UK kidney centres and remained active from December 2021 to April 2022, and a revised version to nurses in late 2022 for additional data. Quantitative data were analysed descriptively. Content analysis on free-text responses identified common themes. RESULTS Analysable responses were received from 41 out of the 68 UK centres (60%), with partial data from an additional 7 (11%). Adaptations were system-wide and affected all aspects of service provision. Some changes were almost universal such as virtual consultations for outpatient appointments, with significant variation in others. Outpatient activity varied from fully maintained to suspended. Many centres reduced peritoneal dialysis access provision but in some this was increased. Centres considered that changes to transplant surgical services and for patients with advanced CKD approaching end-stage kidney disease had the greatest impact on patients. Few centres implemented adjustments aimed at vulnerable and underrepresented groups, including the frail elderly, people with language and communication needs, and those with mental health needs. Communication issues were attributed to rapid evolution of the pandemic, changing planning guidance and lack of resources. Staffing shortages, involving all staff groups particularly nurses, mainly due to COVID-19 infection and redeployment, were compounded by deficiencies in staffing establishments and high vacancy levels. Centres cited three main lessons influencing future service delivery, the need for service redesign, improvements in communication, and better support for staff. CONCLUSION Kidney centre responses to the pandemic involved adaptations across the whole service. Though some changes were almost universal, there was wide variation in other areas. Exploring the role of centre characteristics may help planning for potential future severe service disruptions.
Collapse
Affiliation(s)
- Lucy Mackintosh
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK.
| | - Amanda Busby
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
| | - Ken Farrington
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
- Renal Unit, Lister Hospital, Stevenage, SG1 4AB, UK
| | - Janine Hawkins
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
| | - Sarah Afuwape
- Nephrology, Urology and Renal Transplant, Royal Free London NHS Foundation Trust, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
- Department of Renal Medicine, UCL Medical School, Rowland Hill Street, London, NW3 2PF, UK
| | | | | | - Natalie Hall
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
| | - Tess Harris
- The Polycystic Kidney Disease Charity, 91 Royal College St, London, NW1 0SE, UK
| | - Joanna Hudson
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 5th Floor Bermondsey Wing, Guy's Campus, London Bridge, London, SE1 9RT, UK
| | - Sam Norton
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 5th Floor Bermondsey Wing, Guy's Campus, London Bridge, London, SE1 9RT, UK
| | - Paula Ormandy
- School of Health and Society, University of Salford, Salford, M6 6PU, UK
| | - Christina J Pearce
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 5th Floor Bermondsey Wing, Guy's Campus, London Bridge, London, SE1 9RT, UK
| | - Shalini Santhakumaran
- The UK Kidney Association, Brandon House, Building 20a1, Southmead Road, Bristol, BS34 7RR, UK
| | - Shivani Sharma
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
| | - Sivakumar Sridharan
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
- Renal Unit, Lister Hospital, Stevenage, SG1 4AB, UK
| | - Retha Steenkamp
- The UK Kidney Association, Brandon House, Building 20a1, Southmead Road, Bristol, BS34 7RR, UK
| | - Julie Slevin
- The UK Kidney Association, Brandon House, Building 20a1, Southmead Road, Bristol, BS34 7RR, UK
| | - David Wellsted
- School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, AL10 9AB, UK
| | - Joseph Chilcot
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 5th Floor Bermondsey Wing, Guy's Campus, London Bridge, London, SE1 9RT, UK
| |
Collapse
|
3
|
Kronbichler A, Gregg LP, Bargman JM. The COVID-19 Pandemic: A Special Challenge for the Journal's Editors. J Am Soc Nephrol 2023; 34:1945-1947. [PMID: 37907451 PMCID: PMC10703082 DOI: 10.1681/asn.0000000000000251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - L. Parker Gregg
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas
| | - Joanne M. Bargman
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Knapp CD, Li S, Kou C, Gilbertson DT, Weinhandl ED, Wetmore JB, Hart A, Johansen KL. Increased Access, Persistent Disparities: Trends in Disparities in Peritoneal Dialysis (PD) Use, 2009-2019. Clin J Am Soc Nephrol 2023; 18:1483-1489. [PMID: 37499680 PMCID: PMC10637445 DOI: 10.2215/cjn.0000000000000222] [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: 02/15/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
Peritoneal dialysis (PD) use has increased in the United States since 2009, but how this has affected disparities in PD use is unclear. We used data from the United States Renal Data System to identify a cohort of incident dialysis patients from 2009 to 2019. We used logistic regression models to examine how odds of PD use changed by demographic characteristics. The incident PD population increased by 203% from 2009 to 2019, and the odds of PD use increased in every subgroup. PD use increased more among older people because the odds for those aged 75 years or older increased 15% more per 5-year period compared with individuals aged 18-44 years (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.64 to 1.73 versus OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 5% more per 5-year period among Hispanic people compared with White people (OR 1.58, 95% CI, 1.53 to 1.63 versus OR 1.51, 95% CI, 1.48 to 1.53). There was no difference in odds of PD initiation among people who were Black, Asian, or of another race. The odds of PD use increased 5% more for people living in urban areas compared with people living in nonurban areas (5-year OR 1.54, 95% CI, 1.52 to 1.56 versus 5-year OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 7% more for people living in socioeconomically advantaged areas compared with people living in more deprived areas (5-year OR 1.60, 95% CI, 1.56 to 1.63 for neighborhoods with lowest Social Deprivation Index versus 5-year OR 1.50, 95% CI, 1.48 to 1.53 in the most deprived areas). Expansion of PD use led to a reduction in disparities for older people and for Hispanic people. Although PD use increased across all strata of socioeconomic deprivation, the gap in PD use between people living in the least deprived areas and those living in the most deprived areas widened.
Collapse
Affiliation(s)
- Christopher D. Knapp
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Chuanyu Kou
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- University of Minnesota School of Pharmacy, Minneapolis, Minnesota
- Satellite Healthcare, San Jose, California
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Allyson Hart
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
5
|
Hund HC, Frantz SK, Wu H, Adeniran OR, Wong TY, Borgmann AJ, Matsuoka L, Geevarghese S, Alexopoulos S, Shingina A, Meranze SG, Baker JC, Garbett S, Brown DB. Six-Year Evaluation of Same-Day Discharge following Conventional Transarterial Chemoembolization of Hepatocellular Carcinoma. J Vasc Interv Radiol 2023; 34:378-385. [PMID: 36481322 DOI: 10.1016/j.jvir.2022.11.029] [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: 07/18/2022] [Revised: 11/09/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To evaluate whether same-day discharge increased the incidence of 30-day readmission (30dR) after conventional transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) at a single institution. MATERIALS AND METHODS In this retrospective study, 253 patients with HCC underwent 521 transarterial chemoembolization procedures between 2013 and 2020. TACE was performed with 50-mg doxorubicin/10-mg mitomycin C/5-10-mL ethiodized oil/particles. Patients not requiring intravenous pain medications were discharged after a 3-hour observation, and 30dR was tracked. The primary objective was to determine the incidence of 30dR in same-day discharge patients versus patients admitted for observation using the chi-square test. Secondary objectives assessed factors associated with overnight admission and factors predictive of 30dR using generalized estimated equation calculations and logistic regression. RESULTS In the cohort, 24 readmissions occurred within 30 days (4.6%). Same-day discharge was completed after 331 TACE procedures with sixteen 30dRs (4.8%). Patients admitted overnight were readmitted 8 times after 190 TACE procedures (4.2%). This difference was not statistically significant (P = .4). Factors predicting overnight admission included female sex (58/190 [30.5%] vs 58/331 [17.5%], P < .001) and tumor size of ≥3.8 cm (104/190 [55%] vs 85/190 [45%]). Factors predicting 30dR included female sex (10/116 [8.6%] vs 14/405 [0.2%]) and younger age (median [interquartile range], 63 years [55-65 years] vs 65 years [59-71 years]). At regression, factors predictive of 30dR were Child-Pugh Class B/C (odds ratio [OR], 2.1; P = .04) and female sex (OR, 2.9; P = .004). CONCLUSIONS Same-day discharge after conventional TACE is a safe and effective strategy with 30dR rate of <5%, similar to overnight observation.
Collapse
Affiliation(s)
- Hannah C Hund
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Shelby K Frantz
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hui Wu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oladapo R Adeniran
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas Y Wong
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony J Borgmann
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lea Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sophoclis Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra Shingina
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Steven G Meranze
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer C Baker
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shawn Garbett
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel B Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| |
Collapse
|
6
|
Johansen KL, Li S, Liu J, Weinhandl ED, Gilbertson DT, Kou I, Knapp C, Wetmore JB. Association of the End-Stage Renal Disease Treatment Choices Payment Model With Home Dialysis Use at Kidney Failure Onset From 2016 to 2022. JAMA Netw Open 2023; 6:e230806. [PMID: 36848086 PMCID: PMC9972188 DOI: 10.1001/jamanetworkopen.2023.0806] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services designed a mandatory payment model to incentivize home dialysis use: the End-Stage Renal Disease Treatment Choices (ETC). Outpatient dialysis facilities and health care professionals providing nephrology services were randomly assigned to ETC participation at the hospital referral region level. OBJECTIVE To assess the association between ETC and home dialysis use in the incident dialysis population in its first 18 months of implementation. DESIGN, SETTING, AND PARTICIPANTS A cohort study with controlled, interrupted time series analysis of the US End-Stage Renal Disease Quality Reporting System database was conducted, using generalized estimating equations. All adults initiating home-based dialysis in the US between January 1, 2016, and June 30, 2022, without a prior kidney transplant were included in the analysis. EXPOSURES Prior to vs after ETC onset in January 1, 2021, and random assignment to ETC participation of facilities and health care professionals involved in patient care. MAIN OUTCOMES AND MEASURES Percentage of patients started on incident home dialysis and yearly change in percentage initiating home dialysis. RESULTS A total of 817 177 adults initiated home dialysis during the study period, of whom 750 314 were included in the study cohort. The cohort included 41.4% women; 26.2% of the patients were Black, 17.4% were Hispanic, and 49.1% were White. Approximately half (49.6%) of the patients were aged at least 65 years. A total of 31.2% received care from health care professionals assigned to ETC participation, and 33.6% had Medicare fee-for-service coverage. Overall, home dialysis use increased from 10.0% in January 2016 to 17.4% in June 2022. Home dialysis use increased more in ETC markets than in non-ETC markets after January 2021 (by 1.07%; 95% CI, 0.16%-1.97%). The rate of increase in home dialysis use in the entire cohort nearly doubled after January 2021 to 1.66% per year (95% CI, 1.14%-2.19%) compared with before 2021, when the rate was 0.86% per year (95% CI, 0.75%-0.97%), but the difference in rate of increase in home dialysis use was not significant between ETC and non-ETC markets. CONCLUSIONS AND RELEVANCE This study noted that, although the overall rate of dialysis use at home was greater after ETC implementation, the increase occurred more among patients in ETC markets than among those in non-ETC markets. These findings suggest that federal policy and financial incentives affected care for the entire incident dialysis population in the US.
Collapse
Affiliation(s)
- Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
| | - Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
- Satellite Healthcare, Crestwood, Illinois
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
| | - Iris Kou
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Christopher Knapp
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Nephrology, University of Minnesota, Minneapolis
| |
Collapse
|
7
|
Geetha D, Kronbichler A, Rutter M, Bajpai D, Menez S, Weissenbacher A, Anand S, Lin E, Carlson N, Sozio S, Fowler K, Bignall R, Ducharlet K, Tannor EK, Wijewickrama E, Hafidz MIA, Tesar V, Hoover R, Crews D, Varnell C, Danziger-Isakov L, Jha V, Mohan S, Parikh C, Luyckx V. Impact of the COVID-19 pandemic on the kidney community: lessons learned and future directions. Nat Rev Nephrol 2022; 18:724-737. [PMID: 36002770 PMCID: PMC9400561 DOI: 10.1038/s41581-022-00618-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 12/15/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected patients with kidney disease, causing significant challenges in disease management, kidney research and trainee education. For patients, increased infection risk and disease severity, often complicated by acute kidney injury, have contributed to high mortality. Clinicians were faced with high clinical demands, resource shortages and novel ethical dilemmas in providing patient care. In this review, we address the impact of COVID-19 on the entire spectrum of kidney care, including acute kidney injury, chronic kidney disease, dialysis and transplantation, trainee education, disparities in health care, changes in health care policies, moral distress and the patient perspective. Based on current evidence, we provide a framework for the management and support of patients with kidney disease, infection mitigation strategies, resource allocation and support systems for the nephrology workforce.
Collapse
Affiliation(s)
- Duvuru Geetha
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | | | - Megan Rutter
- Department of Lifespan and Population Health, University of Nottingham, Nottingham, UK
| | - Divya Bajpai
- Department of Nephrology, Seth Gordhandas Sunderdas Medical College (GSMC) and the King Edward Memorial (KEM) Hospital, Mumbai, India
| | - Steven Menez
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Shuchi Anand
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Standford, California, USA
| | - Eugene Lin
- Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, USA
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Stephen Sozio
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin Fowler
- Principal, Voice of the Patient Inc, St. Louis, Missouri, USA
| | - Ray Bignall
- Division of Nephrology and Hypertension, Nationwide Children's Hospital and Department of Paediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathryn Ducharlet
- Department of Renal Medicine, Eastern Health Clinical School, Monash University, Melbourne, Australia
- Department of Nephrology and Palliative Care, St Vincent's Hospital Melbourne, Australia and Department of Medicine, University of Melbourne, Parkville, Australia
| | - Elliot K Tannor
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Renal Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Eranga Wijewickrama
- Consultant Nephrologist and Professor in the Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- University Medical Unit, National Hospital of Sri Lanka and National Institute of Nephrology, Dialysis & Transplantation, Colombo, Sri Lanka
| | | | - Vladimir Tesar
- Department of Nephrology, Charles University, Prague, Czech Republic
| | - Robert Hoover
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Deidra Crews
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles Varnell
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Paediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Lara Danziger-Isakov
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons and the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Chirag Parikh
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Valerie Luyckx
- Associate Scientist, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
- Honorary Associate Professor, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Nephrologist, University Childrens Hospital, Zurich, Switzerland
| |
Collapse
|
8
|
Tummalapalli SL, Navathe AS, Ibrahim SA. Early Findings From Medicare's End-Stage Renal Disease Treatment Choices Model. JAMA HEALTH FORUM 2022; 3:e223500. [PMID: 36206008 PMCID: PMC10133989 DOI: 10.1001/jamahealthforum.2022.3500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science and Innovation, Department of Population Health Sciences and Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Said A Ibrahim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York.,Associate Editor, JAMA Health Forum
| |
Collapse
|
9
|
Weinhandl ED, Liu J, Gilbertson DT, Wetmore JB, Johansen KL. Associations of COVID-19 Outcomes with Dialysis Modalities and Settings. Clin J Am Soc Nephrol 2022; 17:1526-1534. [PMID: 36400565 PMCID: PMC9528267 DOI: 10.2215/cjn.03400322] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
How maintenance dialysis modality, dialysis setting, and residence in a nursing facility have jointly associated with coronavirus disease 2019 (COVID-19)-related outcomes in the United States is relevant to future viral outbreaks. Using Medicare claims, we determined the incidence of COVID-19-related infection, hospitalization, and death between March 15, 2020 and June 5, 2021. The exposure was one of five combinations of dialysis modality and care setting: in-facility hemodialysis without a recent history of skilled nursing facility care, in-facility hemodialysis with a recent history of skilled nursing facility care, hemodialysis in a skilled nursing facility, home hemodialysis, and (home) peritoneal dialysis. Patient-weeks were pooled to estimate the adjusted associations of event incidence with each dialysis modality/setting during four intervals in 2020-2021. Relative to in-facility hemodialysis without a recent history of skilled nursing facility care, home dialysis was associated with 36%-60% lower odds of all events during weeks 12-23 of 2020; 24%-37% lower odds of all events during weeks 24-37 of 2020; 20%-33% lower odds of infection and hospitalization during the winter of 2020-2021; and similar odds of all events thereafter. In contrast, exposure to skilled nursing facilities was associated with 570%-1140% higher odds of all events during spring of 2020, although excess risk attenuated as the pandemic transpired, especially among patients who received hemodialysis in skilled nursing facilities. In conclusion, home dialysis was associated with lower risks of COVID-19 diagnosis, hospitalization, and death until vaccines were available, whereas care in skilled nursing facilities was associated with higher risks.
Collapse
Affiliation(s)
- Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare and the University of Minnesota, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare and the University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
10
|
El Karoui K, De Vriese AS. COVID-19 in dialysis: clinical impact, immune response, prevention, and treatment. Kidney Int 2022; 101:883-894. [PMID: 35176326 PMCID: PMC8842412 DOI: 10.1016/j.kint.2022.01.022] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/01/2022] [Accepted: 01/20/2022] [Indexed: 01/07/2023]
Abstract
The COVID-19 pandemic has profound adverse effects on the population on dialysis. Patients requiring dialysis are at an increased risk of SARS-CoV-2 infection and mortality, and many have experienced psychological distress as well as delayed or suboptimal care. COVID-19 survivors have prolonged viral shedding, but generally develop a robust and long-lasting humoral immune response that correlates with initial disease severity. However, protection against reinfection is incomplete. A growing body of evidence reveals delayed and blunted immune responses to SARS-CoV-2 vaccination. Administration of a third dose within 1 to 2 months of prime-boost vaccination significantly increases antibody levels, in particular in patients with poor initial responses. Patients on dialysis have inferior immune responses to adenoviral vector vaccines than to mRNA vaccines. The immunogenicity of the mRNA-1273 vaccine is markedly better than that of the BNT162b2 vaccine, most likely by virtue of its higher mRNA content. Despite suboptimal immune responses in patients on dialysis, preliminary data suggest that vaccination partially protects against infection and severe disease requiring hospitalization. However, progressive waning of immunity and emergence of SARS-CoV-2 variants with a high potential of immune escape call for a booster dose in all patients on dialysis 4 to 6 months after prime-boost vaccination. Patients with persistent poor vaccine responses may be candidates for primary prophylaxis strategies. In the absence of specific data in patients on dialysis, therapeutic strategies in the event of established COVID-19 must be extrapolated from evidence obtained in the population not on dialysis. Neutralizing monoclonal antibodies may be an attractive option after a high-risk exposure or during the early course of infection.
Collapse
Affiliation(s)
- Khalil El Karoui
- Department of Nephrology and Transplantation, Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire TRUE, Université Paris Est, Créteil, France
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium.
| |
Collapse
|
11
|
COVID-19 and kidney disease: insights from epidemiology to inform clinical practice. Nat Rev Nephrol 2022; 18:485-498. [PMID: 35418695 PMCID: PMC9006492 DOI: 10.1038/s41581-022-00570-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 01/08/2023]
Abstract
Over the course of the COVID-19 pandemic, numerous studies have aimed to address the challenges faced by patients with kidney disease and their caregivers. These studies addressed areas of concern such as the high infection and mortality risk of patients on in-centre haemodialysis and transplant recipients. However, the ability to draw meaningful conclusions from these studies has in some instances been challenging, owing to barriers in aspects of usual care, data limitations and problematic methodological practices. In many settings, access to SARS-CoV-2 testing differed substantially between patient groups, whereas the incidence of SARS-CoV-2 infection varied over time and place because of differences in viral prevalence, targeted public health policies and vaccination rates. The absence of baseline kidney function data posed problems in the classification of chronic kidney disease and acute kidney injury in some studies, potentially compromising the generalizability of findings. Study findings also require attentive appraisal in terms of the effects of confounding, collider bias and chance. As this pandemic continues and in the future, the implementation of sustainable and integrated research infrastructure is needed in settings across the world to minimize infection transmission and both prevent and plan for the short-term and long-term complications of infectious diseases. Registries can support the real-world evaluation of vaccines and therapies in patients with advanced kidney disease while enabling monitoring of rare complications. Patients with kidney disease are at particular risk of the adverse outcomes of COVID-19. Throughout the pandemic, epidemiological studies have been performed to inform clinical care; however, these studies have faced a number of methodological challenges. This Review discusses current understanding of the effects of COVID-19 on patients with kidney disease and some of the major obstacles encountered when conducting epidemiological research in a pandemic setting. Patients who are receiving in-centre dialysis have a higher risk of exposure to SARS-CoV-2 than members of the general population, owing to their limited ability to isolate. Studies have found a dose–response of increasing risk of mortality from COVID-19 with decreasing kidney function, with particularly high mortality seen in people with kidney failure and those on kidney replacement therapy. Evidence of how infection risk can be mitigated in patients with chronic kidney disease is often of poor quality due to the many challenges of conducting epidemiological research in fragmented health-care settings. Observational studies of associations between risk factors, such as chronic kidney disease or transplantation, and outcomes, such as COVID-19-related mortality, can be distorted as a result of collider bias, and thus care must be taken in study design and evaluation. Recognizing the challenges that affect epidemiological studies in pandemic settings together with information on local health contexts enables rigorous assessment of study quality; adequate reporting of aspects relevant to local care availability enables readers to identify studies that contribute robust findings to the literature. To confront the challenges wrought by future pandemics, a sustainable and integrated global infrastructure is needed to identify evidence-based approaches to minimize infection transmission and adverse outcomes.
Collapse
|
12
|
Johansen KL, Chertow GM, Gilbertson DT, Herzog CA, Ishani A, Israni AK, Ku E, Li S, Li S, Liu J, Obrador GT, O'Hare AM, Peng Y, Powe NR, Roetker NS, St Peter WL, Saeed F, Snyder J, Solid C, Weinhandl ED, Winkelmayer WC, Wetmore JB. US Renal Data System 2021 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2022; 79:A8-A12. [PMID: 35331382 PMCID: PMC8935019 DOI: 10.1053/j.ajkd.2022.02.001] [Citation(s) in RCA: 121] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
13
|
Weinhandl ED. The coronavirus disease 2019 pandemic: the disruptor that maintenance dialysis never anticipated. Curr Opin Nephrol Hypertens 2022; 31:185-190. [PMID: 35086986 DOI: 10.1097/mnh.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The novel coronavirus 2019 (COVID-19) pandemic has upended maintenance dialysis in the United States. I review changes in prevalence, incidence, mortality, and other clinical outcomes among patients undergoing dialysis since March 2020, highlighting vulnerabilities in the current system and opportunities for improved care in the future. RECENT FINDINGS The number of dialysis patients in the United States declined between March 2020 and March 2021, an unprecedented year-over-year drop in the census. Some of the decline can be attributed to an early drop in patients initiating dialysis but most of the decline can be attributed to excess mortality. Kidney transplants also declined during the early part of the pandemic. Home dialysis utilization increased during 2020 but that increase was largely in line with secular trends. The rate of hospitalization for causes other than COVID-19 fell significantly during 2020. SUMMARY The epidemiology of dialysis in the United States is clearly modifiable, as it reflects decisions to initiate treatment, prescribe home therapies, and hospitalize patients with acute medical needs. On the other hand, some outcomes are powerfully guided by health outcomes in the general population, thus limiting the ability of dialysis providers and nephrologists to influence outcomes.
Collapse
Affiliation(s)
- Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
14
|
Wetmore JB, Johansen KL, Weinhandl ED. Authors' Reply. J Am Soc Nephrol 2022; 33:455-457. [PMID: 35101996 PMCID: PMC8819993 DOI: 10.1681/asn.2021111417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
15
|
Jacobs L, Devresse A, Baudoux T, Collart F. Confirmed Drop in Treatment of Patients with Incident End-Stage Kidney Disease During the Novel Coronavirus Disease 2019 Pandemic. J Am Soc Nephrol 2022; 33:455. [PMID: 35101995 PMCID: PMC8819998 DOI: 10.1681/asn.2021101296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Lucas Jacobs
- Department of Nephrology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Arnaud Devresse
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Thomas Baudoux
- Department of Nephrology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Frédéric Collart
- Department of Nephrology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| |
Collapse
|
16
|
Niquini RP, Corrêa da Mota J, Bastos LS, da Costa Moreira Barbosa D, Falcão JDS, Palmieri P, Martins P, Melo Villar L, Bastos FI. Persistently high hepatitis C rates in haemodialysis patients in Brazil [a systematic review and meta-analysis]. Sci Rep 2022; 12:330. [PMID: 35013390 PMCID: PMC8748660 DOI: 10.1038/s41598-021-03961-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 12/13/2021] [Indexed: 02/07/2023] Open
Abstract
We conducted a systematic review and meta-analysis of studies assessing HCV infection rates in haemodialysis patients in Brazil (Prospero CRD #42021275068). We included studies on patients under haemodialysis, comprising both convenience samples and exhaustive information from selected services. Patients underwent HCV serological testing with or without confirmation by HCV RNA PCR. Exclusion criteria were the following: absence of primary empirical information and studies without information on their respective settings, study year, accurate infection rates, or full specification of diagnostic tests. Studies with samples ≤ 30 and serial assessments with repeated information were also excluded. Reference databases included PubMed, LILACS, Scopus, and Web of Science for the period 1989–2019. A systematic review was carried out, followed by two independent meta-analyses: (i) studies with data on HCV prevalence and (ii) studies with a confirmatory PCR (i.e., active infection), respectively. A comprehensive set of different methods and procedures were used: forest plots and respective statistics, polynomial regression, meta-regression, subgroup influence, quality assessment, and trim-and-fill analysis. 29 studies and 11,290 individuals were assessed. The average time patients were in haemodialysis varied from 23.5 to 56.3 months. Prevalence of HCV infection was highly heterogeneous, with a pronounced decrease from 1992 to 2001, followed by a plateau and a slight decrease in recent years. The summary measure for HCV prevalence was 34% (95% CI 26–43%) for studies implemented before 2001. For studies implemented after 2001, the corresponding summary measure was 11% (95% CI 8–15%). Estimates for prevalence of active HCV infection were also highly heterogeneous. There was a marked decline from 1996 to 2001, followed by a plateau and a slight increase after 2010. The summary measure for active HCV infection was 19% (95% CI 15–25%) in studies carried out before 2001. For studies implemented after 2001, the corresponding summary measure was 9% (95% CI 6–13%). Heterogeneity was pervasive, but different analyses helped to identify its underlying sources. Besides the year each study was conducted, the findings differed markedly between geographic regions and were heavily influenced by the size of the studies and publication biases. Our systematic review and meta-analysis documented a substantial decline in HCV prevalence among Brazilian haemodialysis patients from 1992 to 2015. CKD should be targeted with specific interventions to prevent HCV infection, and if prevention fails, prompt diagnosis and treatment. Although the goal of HCV elimination by 2030 in Brazil remains elusive, it is necessary to adopt measures to achieve micro-elimination and to launch initiatives towards targeted interventions to curb the spread of HCV in people with CKD, among other high-risk groups. This is of particular concern in the context of a protracted COVID-19 pandemic and a major economic and political crisis.
Collapse
Affiliation(s)
- Roberta Pereira Niquini
- Federal Institute of Education, Science, and Technology of Rio de Janeiro (IFRJ), Rio de Janeiro, Brazil
| | - Jurema Corrêa da Mota
- Institute of Scientific and Technological Communication and Information in Health, Oswaldo Cruz Foundation (ICICT-FIOCRUZ), Biblioteca de Manguinhos suite 229, Av. Brasil 4365, Rio de Janeiro, 21045-900, Brazil
| | - Leonardo Soares Bastos
- Program for Scientific Computing, Oswaldo Cruz Foundation (PROCC-FIOCRUZ), Rio de Janeiro, Brazil
| | | | - Juliane da Silva Falcão
- Federal Institute of Education, Science, and Technology of Rio de Janeiro (IFRJ), Rio de Janeiro, Brazil
| | - Paloma Palmieri
- Institute of Scientific and Technological Communication and Information in Health, Oswaldo Cruz Foundation (ICICT-FIOCRUZ), Biblioteca de Manguinhos suite 229, Av. Brasil 4365, Rio de Janeiro, 21045-900, Brazil
| | - Patrícia Martins
- Laboratory of Viral Hepatitis, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (IOC-FIOCRUZ), Rio de Janeiro, Brazil
| | - Livia Melo Villar
- Laboratory of Viral Hepatitis, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (IOC-FIOCRUZ), Rio de Janeiro, Brazil
| | - Francisco I Bastos
- Institute of Scientific and Technological Communication and Information in Health, Oswaldo Cruz Foundation (ICICT-FIOCRUZ), Biblioteca de Manguinhos suite 229, Av. Brasil 4365, Rio de Janeiro, 21045-900, Brazil.
| |
Collapse
|