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Babroudi S, Weiner DE, Neyra JA, Drew DA. Acute Kidney Injury Receiving Dialysis and Dialysis Care after Hospital Discharge. J Am Soc Nephrol 2024; 35:962-971. [PMID: 38652567 PMCID: PMC11230726 DOI: 10.1681/asn.0000000000000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
The number of patients with AKI receiving outpatient hemodialysis (AKI-D) is increasing. At present, on the basis of limited data, approximately one third of patients with AKI-D who receive outpatient dialysis after hospital discharge survive and regain sufficient kidney function to discontinue dialysis. Data to inform dialysis management strategies that promote kidney function recovery and processes of care among patients with AKI-D receiving outpatient dialysis are lacking. In this article, we detail current trends in the incidence, risk factors, clinical outcomes, proposed management, and health policy landscape for patients with AKI-D receiving outpatient dialysis and identify areas for further research.
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Affiliation(s)
- Seda Babroudi
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Daniel E. Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - David A. Drew
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
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Neyra JA, Gewin L, Ng JH, Barreto EF, Freshly B, Willett J, Abdel-Rahman EM, McCoy I, Kwong YD, Silver SA, Cerda J, Vijayan A. Challenges in the Care of Patients with AKI Receiving Outpatient Dialysis: AKINow Recovery Workgroup Report. KIDNEY360 2024; 5:274-284. [PMID: 38055734 PMCID: PMC10914193 DOI: 10.34067/kid.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/29/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Up to one third of survivors of AKI that required dialysis (AKI-D) during hospitalization remain dialysis dependent at hospital discharge. Of these, 20%-60%, depending on the clinical setting, eventually recover enough kidney function to stop dialysis, and the remainder progress to ESKD. METHODS To describe the challenges facing those still receiving dialysis on discharge, the AKINow Committee conducted a group discussion comprising 59 participants, including physicians, advanced practitioners, nurses, pharmacists, and patients. The discussion was framed by a patient who described gaps in care delivery at different transition points and miscommunication between care team members and the patient. RESULTS Group discussions collected patient perspectives of ( 1 ) being often scared and uncertain about what is happening to and around them and ( 2 ) the importance of effective and timely communication, a comfortable physical setting, and attentive and caring health care providers for a quality health care experience. Provider perspectives included ( 1 ) the recognition of the lack of evidence-based practices and quality indicators, the significant variability in current care models, and the uncertain reimbursement incentives focused on kidney recovery and ( 2 ) the urgency to address communication barriers among hospital providers and outpatient facilities. CONCLUSIONS The workgroup identified key areas for future research and policy change to ( 1 ) improve communication among hospital providers, dialysis units, and patients/care partners; ( 2 ) develop tools for risk classification, subphenotyping, and augmented clinical decision support; ( 3 ) improve education to providers, staff, and patients/care partners; ( 4 ) identify best practices to improve relevant outcomes; ( 5 ) validate quality indicators; and ( 6 ) assess the effect of social determinants of health on outcomes. We urge all stakeholders involved in the process of AKI-D care to align goals and work together to fill knowledge gaps and optimize the care to this highly vulnerable patient population.
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Affiliation(s)
- Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Leslie Gewin
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Jia H. Ng
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine, Hempstead, New York
| | | | | | - Jeff Willett
- ASN: American Society of Nephrology, Washington, DC
| | - Emaad M. Abdel-Rahman
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Ian McCoy
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Yuenting D. Kwong
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Samuel A. Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
| | - Jorge Cerda
- Division of Nephrology, Department of Medicine, Albany Medical College, Albany, New York
| | - Anitha Vijayan
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
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McLarnon SR. Pathophysiology of Red Blood Cell Trapping in Ischemic Acute Kidney Injury. Compr Physiol 2023; 14:5325-5343. [PMID: 38158367 DOI: 10.1002/cphy.c230010] [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] [Indexed: 01/03/2024]
Abstract
Red blood cell (RBC) trapping describes the accumulation of RBCs in the microvasculature of the kidney outer medulla that occurs following ischemic acute kidney injury (AKI). Despite its prominence in human kidneys following AKI, as well as evidence from experimental models demonstrating that the severity of RBC trapping is directly correlated with renal recovery, to date, RBC trapping has not been a primary focus in understanding the pathogenesis of ischemic kidney injury. New evidence from rodent models suggests that RBC trapping is responsible for much of the tubular injury occurring in the initial hours after kidney reperfusion from ischemia. This early injury appears to result from RBC cytotoxicity and closely reflects the injury profile observed in human kidneys, including sloughing of the medullary tubules and the formation of heme casts in the distal tubules. In this review, we discuss what is currently known about RBC trapping. We conclude that RBC trapping is likely avoidable. The primary causes of RBC trapping are thought to include rheologic alterations, blood coagulation, tubular cell swelling, and increased vascular permeability; however, new data indicate that a mismatch in blood flow between the cortex and medulla where medullary perfusion is maintained during cortical ischemia is also likely critical. The mechanism(s) by which RBC trapping contributes to renal functional decline require more investigation. We propose a renewed focus on the mechanisms mediating RBC trapping, and RBC trapping-associated injury is likely to provide important knowledge for improving AKI outcomes. © 2024 American Physiological Society. Compr Physiol 14:5325-5343, 2024.
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Affiliation(s)
- Sarah R McLarnon
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Lai CF, Liu JH, Tseng LJ, Tsao CH, Chou NK, Lin SL, Chen YM, Wu VC. Unsupervised clustering identifies sub-phenotypes and reveals novel outcome predictors in patients with dialysis-requiring sepsis-associated acute kidney injury. Ann Med 2023; 55:2197290. [PMID: 37043222 PMCID: PMC10101673 DOI: 10.1080/07853890.2023.2197290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 03/25/2023] [Indexed: 04/13/2023] Open
Abstract
INTRODUCTION Heterogeneity exists in sepsis-associated acute kidney injury (SA-AKI). This study aimed to perform unsupervised consensus clustering in critically ill patients with dialysis-requiring SA-AKI. PATIENTS AND METHODS This prospective observational cohort study included all septic patients, defined by the Sepsis-3 criteria, with dialysis-requiring SA-AKI in surgical intensive care units in Taiwan between 2009 and 2018. We employed unsupervised consensus clustering based on 23 clinical variables upon initializing renal replacement therapy. Multivariate-adjusted Cox regression models and Fine-Gray sub-distribution hazard models were built to test associations between cluster memberships with mortality and being free of dialysis at 90 days after hospital discharge, respectively. RESULTS Consensus clustering among 999 enrolled patients identified three sub-phenotypes characterized with distinct clinical manifestations upon renal replacement therapy initiation (n = 352, 396 and 251 in cluster 1, 2 and 3, respectively). They were followed for a median of 48 (interquartile range 9.5-128.5) days. Phenotypic cluster 1, featured by younger age, lower Charlson Comorbidity Index, higher baseline estimated glomerular filtration rate but with higher severity of acute illness was associated with an increased risk of death (adjusted hazard ratio of 3.05 [95% CI, 2.35-3.97]) and less probability to become free of dialysis (adjusted sub-distribution hazard ratio of 0.55 [95% CI, 0.38-0.8]) than cluster 3. By examining distinct features of the sub-phenotypes, we discovered that pre-dialysis hyperlactatemia ≥3.3 mmol/L was an independent outcome predictor. A clinical model developed to determine high-risk sub-phenotype 1 in this cohort (C-static 0.99) can identify a sub-phenotype with high in-hospital mortality risk (adjusted hazard ratio of 1.48 [95% CI, 1.25-1.74]) in another independent multi-centre SA-AKI cohort. CONCLUSIONS Our data-driven approach suggests sub-phenotypes with clinical relevance in dialysis-requiring SA-AKI and serves an outcome predictor. This strategy represents further development toward precision medicine in the definition of high-risk sub-phenotype in patients with SA-AKI.Key messagesUnsupervised consensus clustering can identify sub-phenotypes of patients with SA-AKI and provide a risk prediction.Examining the features of patient heterogeneity contributes to the discovery of serum lactate levels ≥ 3.3 mmol/L upon initializing RRT as an independent outcome predictor.This data-driven approach can be useful for prognostication and lead to a better understanding of therapeutic strategies in heterogeneous clinical syndromes.
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Affiliation(s)
- Chun-Fu Lai
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Jung-Hua Liu
- Department of Communication, National Chung Cheng University, Minhsiung, Taiwan
| | - Li-Jung Tseng
- Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chun-Hao Tsao
- Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Nai-Kuan Chou
- Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
- Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Yung-Ming Chen
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
- National Taiwan University Hospital Bei-Hu Branch, Taipei City, Taiwan
| | - Vin-Cent Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
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McCoy IE, Weinhandl E, Hussein W, Hsu CY. Initial Management and Potential Opportunities to Deprescribe Dialysis among Patients with AKI-D Patients after Hospital Discharge. J Am Soc Nephrol 2023; 34:1949-1951. [PMID: 37768189 PMCID: PMC10703077 DOI: 10.1681/asn.0000000000000225] [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: 07/04/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
SIGNIFICANCE STATEMENT Dialysis-requiring AKI (AKI-D) now accounts for more than 15% of outpatient hemodialysis initiations; over 30% of these patients with AKI-D may have potential to recover. However, little is known about strategies currently used to treat outpatient AKI-D and screen for recovery. In this study of 1754 patients with AKI-D, we found that ( 1 ) the initial dialysis orders were similar to those of patients with contemporary incident ESKD, despite different treatment goals; ( 2 ) timed urine collections were completed in only a minority of patients; and ( 3 ) most patients with AKI-D who recovered discontinued dialysis without ever having been weaned from their initial dialysis prescription, suggesting there may be substantial opportunity to wean dialysis sooner.
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Affiliation(s)
- Ian E. McCoy
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Eric Weinhandl
- Satellite Healthcare, Inc., San Jose, California
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Wael Hussein
- Satellite Healthcare, Inc., San Jose, California
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Chi-yuan Hsu
- Division of Nephrology, University of California San Francisco, San Francisco, California
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Hsu RK, Rubinsky AD, Shlipak MG, Johansen KL, Estrella MM, Lee BJ, Peralta CA, Hsu CY. Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans. BMC Nephrol 2023; 24:339. [PMID: 37964185 PMCID: PMC10647139 DOI: 10.1186/s12882-023-03387-9] [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: 12/09/2022] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Mortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function-an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD-are associated with early mortality after dialysis initiation. METHODS We extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009-2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD. RESULTS Twenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66-2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90-2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N = 2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01-1.40). CONCLUSIONS An abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.
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Affiliation(s)
- Raymond K Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Anna D Rubinsky
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Michael G Shlipak
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kirsten L Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Nephrology, Hennepin Healthcare, Minneapolis, MN, USA
| | - Michelle M Estrella
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Benjamin J Lee
- Houston Methodist Institute for Academic Medicine, Houston, TX, USA
- Houston Kidney Consultants, Houston, TX, USA
| | - Carmen A Peralta
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Medicine, Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Cricket Health, Inc, San Francisco, CA, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Wu CY, Liu JS, Chen CH, Huang CT, Yu TM, Chuang YW, Huang ST, Hsu CC, Wu MJ. Early Comprehensive Kidney Care in Dialysis-Requiring Acute Kidney Injury Survivors: A Populational Study. Front Med (Lausanne) 2022; 9:847462. [PMID: 35530035 PMCID: PMC9072865 DOI: 10.3389/fmed.2022.847462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundFor patients with Acute Kidney Injury (AKI), a strong and graded relationship exists between AKI severity and mortality. One of the most severe entities of AKI is Dialysis-Requiring Acute Kidney Injury (D-AKI), which is associated with high rates of mortality and end-stage renal disease (ESRD). For this high-risk population group, there is a lack of evidence regarding optimal post-AKI care. We propose that post-AKI care through the combined efforts of the nephrologist and the multidisciplinary care team may improve outcomes. Our aim here is to study for survivors of dialysis-requiring acute kidney injury, the effects of implementing early comprehensive kidney care.MethodsThis is a retrospective longitudinal cohort study of Taiwanese through analyzing the National Health Insurance Research Database (NHIRD). We included patients with acute dialysis during hospitalization from January 1, 2015 to December 31, 2018. Propensity match was done at 1:1, including estimated glomerular filtration rate (eGFR) based on CKD-EPI which was performed due to large initial disparities between these two cohorts.ResultsAfter the propensity match, each cohort had 4,988 patients. The mean eGFR based on CKD-EPI was 27.5 ml/min/1.73 m2, and the mean follow-up period was 1.4 years.The hazard ratio for chronic dialysis or ESRD was 0.55 (95% CI, 0.49–0.62; p < 0.001). The hazard ratio for all-cause mortality was 0.79 (95% CI, 0.57–0.88; p < 0.001). Both outcomes favored early comprehensive kidney care.ConclusionsFor survivors of dialysis-requiring acute kidney injury, early comprehensive kidney care significantly lowered risks of chronic dialysis and all-cause mortality.
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Affiliation(s)
- Chun-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Nursing, Asia University, Taichung, Taiwan
| | - Jia-Sin Liu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Post-baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Life Science, Tunghai University, Taichung, Taiwan
| | - Chun-Te Huang
- Department of Internal Medicine and Critical Care Medicine, Nephrology and Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tung-Min Yu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ya-Wen Chuang
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Post-baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
| | - Shih-Ting Huang
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
- Department of Family Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Miaoli, Taiwan
- *Correspondence: Chih-Cheng Hsu
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- RongHsing Research Center for Translational Medicine, College of Life Sciences, National Chung Hsing University, Taichung, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Ming-Ju Wu
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McCoy I, Hsu CY. Dialyzing Acute Kidney Injury Patients after Hospital Discharge. Clin J Am Soc Nephrol 2021; 16:848-849. [PMID: 34117078 PMCID: PMC8216627 DOI: 10.2215/cjn.04590421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Ian McCoy
- Division of Nephrology, University of California San Francisco School of Medicine, San Francisco, California
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