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Abstract
Rationale & Objective The Kidney Failure Risk Equation (KFRE) is a simple widely validated prediction model using age, sex, estimated glomerular filtration rate, and urinary albumin-creatinine ratio to predict the risk for end-stage kidney disease. Data are limited for its applicability to kidney transplant recipients. Study Design Validation study of the KFRE as a post hoc analysis of the Folic Acid for Vascular Outcomes Reduction in Transplantation (FAVORIT) Trial. Setting & Participants Adult kidney transplant recipients with functioning kidney allografts at least 6 months posttransplantation from 30 centers in the United States, Canada, and Brazil. Participants with estimated glomerular filtration rates < 60 mL/min/1.73 m2 at study entry were included. Predictor 2- and 5-year kidney failure risk predicted by the KFRE using variables at study entry. Outcome Graft loss, defined by initiation of dialysis. Analytical Approach Discrimination of the KFRE was assessed using C statistics; calibration was assessed by plotting predicted risk against observed cumulative incidence of graft loss. Results 2,889 participants were included. Within 2 years, 98 participants developed graft loss, 107 participants died with a functioning graft, and 129 participants were lost to follow-up, and by 5 years, 252 had developed graft loss, 265 died with a functioning graft, and 1,543 were lost to follow-up. The KFRE demonstrated accurate calibration and discrimination (C statistic, 0.85 [95% CI, 0.81-0.88] at 2 years and 0.81 [95% CI, 0.78-0.84] at 5 years); performance was similar regardless of donor type (living vs deceased) and graft vintage, with the noted exception of poorer calibration for graft vintage less than 2 years. Limitations Unavailable cause of graft loss. Conclusions The KFRE accurately predicted the risk for graft loss among adult kidney transplant recipients with graft vintage longer than 2 years and may be a useful prognostic tool for nephrologists caring for kidney transplant recipients.
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Montero N, Codina S, Cruzado JM. Prediction scores for risk of allograft loss in patients receiving kidney transplants: nil satis nisi optimum. Clin Kidney J 2020; 13:745-748. [PMID: 33125003 PMCID: PMC7577772 DOI: 10.1093/ckj/sfaa081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/21/2020] [Indexed: 12/16/2022] Open
Abstract
Long-term graft survival is the main concern of kidney transplantation. Some strategies have been tested to predict graft survival using estimated glomerular filtration rate or proteinuria at different time points, histologic assessment, non-invasive biomarkers or even machine-learning methods. However, the 'magical formulae' for allograft survival prediction does not exist yet.
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Affiliation(s)
- Nuria Montero
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), L’ Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
| | - Sergi Codina
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), L’ Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
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3
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Okuda Y, Streja E, Rhee CM, Tantisattamo E, Reddy U, Laster M, Tang Y, Rajpoot D, Molnar MZ, Ichii H, Obi Y, Kalantar-Zadeh K. Association of age with risk of first and subsequent allograft failure and mortality among young kidney transplant recipients in the USA - a retrospective cohort study. Transpl Int 2020; 33:1503-1515. [PMID: 32779214 DOI: 10.1111/tri.13717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/20/2020] [Accepted: 08/05/2020] [Indexed: 11/30/2022]
Abstract
Adolescent age may be a high-risk period for kidney allograft failure. However, the knowledge on this topic is limited mostly to the first transplant. Among 20 960 patients aged ≤21 years at the first kidney transplantation from the US Renal Data System, we evaluated the association of age at the first kidney transplant with risk for the first and subsequent graft failures (1st, 2nd, and 3rd) using the conditional risk set model for recurrent time-to-event data. The median age was 15 (interquartile range: 9-18) years, and 18% received transplants twice or more during a median follow-up of 9.7 years. The risk for graft failures was highest in 16 to <18 years old with an adjusted hazard ratio (aHR) of 1.93 (95% CI, 1.73-2.15; reference: <3 years). When separately analyzed, the highest risk was observed in 17, 19, and 21 years old for the first, second, and third transplant, respectively. Those 16 to <18 years were also strongly associated with the highest risk for death after returning to dialysis (aHR, 4.01; 95% CI, 2.82-5.71). Adolescent recipients remain at high risk for allograft failure for a long time, which may result in high mortality risk, even though they surpass this high-risk period soon after the first transplant.
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Affiliation(s)
- Yusuke Okuda
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA.,Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, JAPAN
| | - Elani Streja
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA
| | - Connie M Rhee
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA
| | - Ekamol Tantisattamo
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA
| | - Uttam Reddy
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA
| | - Marciana Laster
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
| | - Ying Tang
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA.,Department of Pediatric Nephrology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Deepak Rajpoot
- Miller Children Hospital, Long Beach, CA, USA.,Department of Pediatrics, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Miklos Z Molnar
- James D Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hirohito Ichii
- Department of Surgery, University of California Irvine, Orange, CA, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA
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Lubas MM, Ware JC, Szklo-Coxe M. Sleep apnea and kidney transplant outcomes: findings from a 20-year (1997-2017) historical cohort study. Sleep Med 2019; 63:151-158. [PMID: 31669818 DOI: 10.1016/j.sleep.2019.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/14/2019] [Accepted: 05/29/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE/BACKGROUND A historic cohort single-center study of kidney transplant recipients with graft loss examined the associations between sleep apnea and two transplant outcomes, death with a functioning graft (DWFG), and graft survival time. PATIENT/METHODS Adult patients who received transplants and experienced graft failure or DWFG from January 1, 1997 to January 1, 2017 constituted the cohort (n = 322). Data for the study were obtained by merging two secondary data sources: the Organ Procurement and Transplantation Network (OPTN) database and the transplant center's medical records. A Cox regression modeled the association of diagnosed sleep apnea, stratified by year-of transplant surgery, with graft survival time. Using backward elimination, this model was adjusted for recipient age, race/ethnicity, gender, functional status, donor age, and antigen mismatch. RESULTS No statistically significant differences were found for proportions of DWFG in those with, versus without, sleep apnea, informing our censoring approach. When examining graft survival time, the Cox regression model was stratified given a sleep apnea and year-of-transplant interaction (p < 0.01, adjusted model). For patients transplanted between 1997 and 2008, sleep apnea was statistically significantly associated with a decreased risk of graft failure or cardiovascular-related DWFG [adjusted Hazard Ratio (aHR) = 0.63, 95%CI, 0.42-0.94]. For patients transplanted between 2009 and 2017, sleep apnea statistically significantly increased the risk of graft failure or cardiovascular-related DWFG (aHR = 2.61, 95%CI, 1.13-6.00). CONCLUSIONS In a cohort of transplant recipients with graft loss, sleep apnea increased the risk of graft loss nearly three-fold among patients transplanted between 2009 and 2017. Similar DWFG proportions by sleep apnea presence indicate this risk is likely driven by renal failure, not mortality. Further research on whether treatment of sleep apnea can improve graft survival is warranted.
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Affiliation(s)
- Margaret M Lubas
- School of Community and Environmental Health, College of Health Sciences, Old Dominion University, Norfolk, VA, USA
| | - J Catesby Ware
- Division of Sleep Medicine, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Mariana Szklo-Coxe
- School of Community and Environmental Health, College of Health Sciences, Old Dominion University, Norfolk, VA, USA; Division of Sleep Medicine, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.
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Mason SA, Nathens AB, Byrne J, Gonzalez A, Fowler R, Karanicolas P, Moineddin R, Jeschke MG. Trends in the epidemiology of major burn injury among hospitalized patients: A population-based analysis. J Trauma Acute Care Surg 2017; 83:867-874. [PMID: 28538640 PMCID: PMC5656518 DOI: 10.1097/ta.0000000000001586] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Burn-related mortality has decreased significantly over the past several decades. Although often attributed in part to regionalization of burn care, this has not been evaluated at the population level. METHODS We conducted a retrospective, population-based cohort study of all patients with 20% or higher total body surface area burn injury in Ontario, Canada. Adult (≥16 years) patients injured between 2003 and 2013 were included. Deaths in the emergency department were excluded. Logistic generalized estimating equations were used to estimate risk-adjusted 30-day mortality. Mortality trends were compared at burn and nonburn centers. RESULTS Seven hundred seventy-two patients were identified at 84 centers (2 burn, 82 nonburn). Patients were 74% (n = 570) male, of median age 46 (interquartile range [IQR], 35-60) years and median total body surface area 35% (IQR, 25-45). Mortality at 30 days was 19% (n = 149). The proportion of patients treated at a burn center increased from 57% to 71% between 2003 and 2013 (p = 0.07). Average risk-adjusted 30-day mortality rates decreased over time; there were significantly reduced odds of death in 2010 to 2013 compared with 2003 to 2006 (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.25-0.61). Burn centers exhibited significantly reduced mortality from 2003-2006 to 2010-2013 (OR, 0.36; 95% CI, 0.34-0.38) compared with nonburn centers (OR, 0.41; 95% CI, 0.13-1.24). CONCLUSION Mortality rates have decreased over time; significant improvements have occurred at burn centers, whereas mortality rates at nonburn centers vary widely. A high proportion of patients continue to receive care outside of burn centers. These data suggest that there are further opportunities to regionalize burn care and in so doing, potentially lower burn-related mortality. LEVEL OF EVIDENCE Epidemiological study, level III; Therapy, level IV.
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Affiliation(s)
- Stephanie A. Mason
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Avery B. Nathens
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - James Byrne
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | | | - Rob Fowler
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care, University of Toronto
| | - Paul Karanicolas
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre and Division of General Surgery, University of Toronto, Toronto, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Rahim Moineddin
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto
| | - Marc G. Jeschke
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre and Division of Plastic Surgery, University of Toronto, Toronto, Canada
- Institute for Medical Sciences, University of Toronto, Toronto, Canada
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Wekerle T, Segev D, Lechler R, Oberbauer R. Strategies for long-term preservation of kidney graft function. Lancet 2017; 389:2152-2162. [PMID: 28561006 DOI: 10.1016/s0140-6736(17)31283-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/13/2017] [Accepted: 03/16/2017] [Indexed: 12/21/2022]
Abstract
Kidney transplantation has become a routine procedure in the treatment of patients with kidney failure, and requires collaboration of experts from different disciplines, such as nephrology, surgery, immunology, pathology, infectious disease medicine, cardiology, and oncology. Grafts can be obtained from deceased or living donors, with different logistical requirements and implications for long-term graft patency. 1-year graft survival rates are greater than 95% in many centres but improvement of long-term function remains a challenge. New developments in molecular immunology and computational biology have increased precision of donor and recipient matching of HLA and non-HLA compatibility. Individual omics-wide molecular diagnostics, extracorporeal therapies, and drug developments allow for precise individual decision making and treatment. Tolerance induction by mixed chimerism without toxic conditioning and with a low risk of graft versus host disease is a visionary but realistic goal. Some of these innovations are already used in modern transplant centres and will allow advancement in long-term allograft preservation.
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Affiliation(s)
- Thomas Wekerle
- Department of Surgery, Section of Transplantation Immunology, Medical University of Vienna, Vienna, Austria
| | - Dorry Segev
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Lechler
- MRC Centre for Transplantation, King's College London, London, UK
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria.
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Molnar AO, van Walraven C, Fergusson D, Garg AX, Knoll G. Derivation of a Predictive Model for Graft Loss Following Acute Kidney Injury in Kidney Transplant Recipients. Can J Kidney Health Dis 2017; 4:2054358116688228. [PMID: 28270930 PMCID: PMC5308519 DOI: 10.1177/2054358116688228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/13/2016] [Indexed: 01/06/2023] Open
Abstract
Background: Acute kidney injury (AKI) is common in the kidney transplant population. Objective: To derive a multivariable survival model that predicts time to graft loss following AKI. Design: Retrospective cohort study using health care administrative and laboratory databases. Setting: Southwestern Ontario (1999-2013) and Ottawa, Ontario, Canada (1996-2013). Patients: We included first-time kidney only transplant recipients who had a hospitalization with AKI 6 months or greater following transplant. Measurements: AKI was defined using the Acute Kidney Injury Network criteria (stage 1 or greater). The first episode of AKI was included in the analysis. Graft loss was defined by return to dialysis or repeat kidney transplant. Methods: We performed a competing risk survival regression analysis using the Fine and Gray method and modified the model into a simple point system. Graft loss with death as a competing event was the primary outcome of interest. Results: A total of 315 kidney transplant recipients who had a hospitalization with AKI 6 months or greater following transplant were included. The median (interquartile range) follow-up time was 6.7 (3.3-10.3) years. Graft loss occurred in 27.6% of the cohort. The final model included 6 variables associated with an increased risk of graft loss: younger age, increased severity of AKI, failure to recover from AKI, lower baseline estimated glomerular filtration rate, increased time from kidney transplant to AKI admission, and receipt of a kidney from a deceased donor. The risk score had a concordance probability of 0.75 (95% confidence interval [CI], 0.69-0.82). The predicted 5-year risk of graft loss fell within the 95% CI of the observed risk more than 95% of the time. Limitations: The CIs of the estimates were wide, and model overfitting is possible due to the limited sample size; the risk score requires validation to determine its clinical utility. Conclusions: Our prognostic risk score uses commonly available information to predict the risk of graft loss in kidney transplant patients hospitalized with AKI. If validated, this predictive model will allow clinicians to identify high-risk patients who may benefit from closer follow-up or targeted enrollment in future intervention trials designed to improve outcomes.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Carl van Walraven
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ontario, Canada; Department of Medicine, University of Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada
| | - Greg Knoll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ontario, Canada; Division of Nephrology, Department of Medicine, University of Ottawa, Ontario, Canada
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Fonseca I, Teixeira L, Malheiro J, Martins LS, Dias L, Castro Henriques A, Mendonça D. The effect of delayed graft function on graft and patient survival in kidney transplantation: an approach using competing events analysis. Transpl Int 2015; 28:738-50. [PMID: 25689397 DOI: 10.1111/tri.12543] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 11/30/2014] [Accepted: 02/06/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In kidney transplantation, the impact of delayed graft function (DGF) on long-term graft and patient survival is controversial. We examined the impact of DGF on graft and recipient survival by accounting for the possibility that death with graft function may act as a competing risk for allograft failure. STUDY DESIGN AND SETTING We used data from 1281 adult primary deceased-donor kidney recipients whose allografts functioned at least 1 year. RESULTS The probability of graft loss occurrence is overestimated using the complement of Kaplan-Meier estimates (1-KM). Both the cause-specific Cox proportional hazard regression model (standard Cox) and the subdistribution hazard regression model proposed by Fine and Gray showed that DGF was associated with shorter time to graft failure (csHR = 2.0, P = 0.002; sHR = 1.57, P = 0.009), independent of acute rejection (AR) and after adjusting for traditional factors associated with graft failure. Regarding patient survival, DGF was a predictor of patient death using the cause-specific Cox model (csHR = 1.57, P = 0.029) but not using the subdistribution model. CONCLUSIONS The probability of graft loss from competing end points should not be reported with the 1-KM. Application of a regression model for subdistribution hazard showed that, independent of AR, DGF has a detrimental effect on long-term graft survival, but not on patient survival.
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Affiliation(s)
- Isabel Fonseca
- Department of Nephrology and Kidney Transplantation, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal.,Unit for Multidisciplinary Investigation in Biomedicine (UMIB), Porto, Portugal.,EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Laetitia Teixeira
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal.,Department of Population Studies, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | - Jorge Malheiro
- Department of Nephrology and Kidney Transplantation, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal.,Unit for Multidisciplinary Investigation in Biomedicine (UMIB), Porto, Portugal
| | - La Salete Martins
- Department of Nephrology and Kidney Transplantation, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal.,Unit for Multidisciplinary Investigation in Biomedicine (UMIB), Porto, Portugal
| | - Leonídio Dias
- Department of Nephrology and Kidney Transplantation, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - António Castro Henriques
- Department of Nephrology and Kidney Transplantation, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal.,Unit for Multidisciplinary Investigation in Biomedicine (UMIB), Porto, Portugal
| | - Denisa Mendonça
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal.,Department of Population Studies, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal
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