AUSTRALIAN ESKD HOT SPOTS

S MCDONALD1,2,3, S JESUDASON1,2,3
1Anzdata Registry, SAHMRI, Adelaide, Australia, 2Renal Unit, Royal Adelaide Hospital, Adelaide, Australia, 3University of Adelaide, Adelaide, Australia

Aim: Describe and plot geographical variation in ESKD incidence
Background: ESKD incidence in Australia has been well described in relation to clinical characteristics, but not geographic characteristics and spatial relationships.
Methods: Data from ABS and ANZDATA Registry data incident ESKD patients from 2012-16 were analysed to determine rates of new treated ESKD (dialysis and transplantation) in a geospatial framework. On the basis of residential postcodes, incidence rates overall and for various pre-defined sub-groups were determined for each statistical area level 3 (SA3 – typically 30-100,000 population). Detailed “heat maps” of ESKD incidence for Australia were created.
Results: Overall incidence was 116 per million per year (pmpy). The highest rates were noted in the Barkly region, NT (1058 [95% CI 732-1479] pmpy) ;  Alice Springs (973 [842-1118] pmpy)  and Katherine( 620 [479-791] pmpy). These “hot-spots” were associated with high proportions of Aboriginal and Torres Strait Islander population. Analyses restricted to non-indigenous populations revealed the areas of highest incidence were Biloela (Qld; 408 [95% CI 273-586] pmpy) followed by East Pilbara, Colac, Noosa and Goulbourn-Mulwaree. The highest absolute rates overall and for both indigenous and non-indigenous rates were in non-urban areas.
Conclusions: Linking of Registry information with geospatial data offers useful insights into disease patterns and service demands. Heat maps provide a powerful visual way of showing this data, and linking to other non-medical factors including community characteristics. In addition to SA3 areas, other potentially useful area for analysis include local government areas, “greater metropolitan” areas and hospital/health service catchment areas.


Biography:
Prof Stephen McDonald is Director of Dialysis at the Central Northern Adelaide Renal and Transplantation Service, Clinical Director of Renal Services for Country Health SA and Executive Officer of the Australia and New Zealand Dialysis and Transplant Registry. He also is a Clinical Professor in the Adelaide Medical School, and Principal Research Fellow in the SA Health and Medical Research institute (SAHMRI).

A HIGH PREVALENCE OF GLOMERULONEPHRITIDES WITHIN THE ELDERLY POPULATION: AN AUDIT OF RENAL BIOPSIES IN GREATER WESTERN SYDNEY

S SO1,2, B BOSE1,3, E FISCHER1, M KOMALA1,3, K SUD1,3, N WONG1
1Department of Renal Medicine, Nepean Hospital, Kingswood, Australia, 2Department of Renal Medicine, Westmead Hospital, Westmead, Australia, 3University of Sydney, Nepean Clinical School, Kingswood, Australia

Aim: To retrospectively analyse the prevalence of renal histopathology diagnoses in elderly patients in the Nepean Blue Mountains Local Health District (NBMLHD) over 10 years.
Background: NBMLHD services a population numbering over 345,000. Australia’s elderly population (aged 65 and over) continues to grow, reflected in patient demographics. This audit describes the renal histopathology diagnoses in the elderly population in greater Western Sydney, a growing area of healthcare need.
Methods: Demographic, laboratory and renal histopathology data was collected from electronic health records in all patients aged 65 years and over who had a renal biopsy from 2008-2017. All biopsies were performed under radiologic guidance and analysed at Westmead Hospital histopathology laboratory.
Results: Of 117 biopsies, three were excluded because of inadequate sampling. The median age at biopsy was 71.6 years (65-86.6). 50 biopsies (44.2%) revealed glomerulonephritides (17 ANCA-associated vasculitis, 9 IgA nephropathy, 8 membranoproliferative glomerulonephritis, 7 membranous nephropathy, 9 other including focal segmental glomerulosclerosis, minimal change disease and lupus nephritis). Diabetic nephropathy was the next most common in 12 biopsies (10.6%), followed by hypertensive or ischaemic nephropathy in 8 (7%), amyloidosis in 8 biopsies and acute tubular necrosis in 8 biopsies. 7 biopsies (6.2%) showed interstitial nephritis. 20 biopsies showed other changes, including 2 thrombotic microangiopathy, 1 cast nephropathy and 1 oxalate nephropathy. One biopsy was normal.
Conclusions: Although we acknowledge the selection bias in our population, our audit of histopathological diagnoses in the elderly found a high prevalence of glomerulonephritides. This highlights that age should not be an absolute contraindication for renal biopsies, as these diagnoses have implications on management and clinical outcomes. This may help guide informed decision-making for both nephrologists and elderly patients.


Biography:
Dr So is a second-year renal advanced trainee in the Western Sydney renal network.

GEOGRAPHICAL RELOCATION IN AUSTRALIAN PATIENTS RECEIVING RENAL REPLACEMENT THERAPY

H HASSAN1,2, K MURALI1
1Wollongong Hospital Renal Unit, Wollongong, Australia, 2University of Wollongong, Wollongong, Australia

Aim: Determine the characteristics of Australian patients on renal replacement therapy (RRT) who relocate.
Background: RRT patients have the risk of being tied down geographically to treatment centres. The need for receiving RRT can impact the relocation decisions of RRT patients.
Methods: Cohort epidemiological study of Australian adults commencing RRT (2005-2015) based on ANZDATA registry. Relocation defined as change in postcode. Dialysis modality, urbanity and patient characteristics examined. Remoteness areas (RA) defined by Accessibility / Remoteness index of Australia (ARIA).
Results: Out of 24,676 patients most (70.4%) commenced RRT in major city (MC) and majority (66.6%) started hospital haemodialysis. Prevalence of relocation was 23.9% with median time to relocation 1.6 years [IQR 0.7,3.4]. Relocation incidence increased by urbanity (7.2/100ptyrs (95%CI 6.5-7.8) in MC to 48.8/100ptyrs (95%CI 45.6-51.9) in Very Remote (VR)). Relocating patients were younger (55.4 vs 61.8 years, p<0.001). Patients with comorbidities relocated sooner (1.5 vs2.1 years, p<0.001). Majority (70.6%) relocations occurred within the same RA category indicating patient needs /choice.  Australian Indigenous (OR 2.7, 95% CI 2.5-2.9) & Maori (OR 1.5, 95% CI 1.3-1.8) people, compared to Caucasians and VR (OR 7.2, 95% CI 6.2-8.3) & Remote (OR 1.8, 95% CI: 1.5-2.1) patients compared to MC, were more likely to relocate. Most VR (97.3%) and majority Remote (70%) patients relocated to higher RA category, with shorter relocation time (0.6 years VR, 1.1 R, 1.9 MC, p<0.001). Using a multi-variate model most of the Indigenous relocations were explained by the remoteness.
Conclusion: Most relocations in RRT patients are driven by patient needs/choice. Relocation patterns in VR / Remote patients and Indigenous subjects suggests that RRT treatment needs may be driving relocation, highlighting geographical disadvantage.


Biography:
Consultant Nephrologist. Wollongong Hospital

ESTIMATED INCIDENCE OF ACUTE KIDNEY INJURY AFTER PERCUTANEOUS CORONARY INTERVENTION BY TWO DENOMINATORS

M JIANG1, W KUO1
1Chi Mei Medical Center, Tainan, Taiwan

Aim: We aimed to compare the incidence of acute kidney injury (AKI) after percutaneous coronary intervention (PCI) by different denominators and AKI definitions in a single population.
Background: AKI is a common complication among patients undergoing PCI. Estimated incidence of AKI after PCI varied widely because of diverse AKI definitions, denominators, sample sizes and populations.
Methods: We retrospectively reviewed the medical records of 4,638 patients undergoing PCIs at a tertiary care center. We excluded patients who received dialysis before PCI (467 patients) and those whose baseline serum creatinine were missing (6 patients), contributing to denominator 1 (n=4165 patients). We further excluded 2961 patients whose post-procedural creatinine were unavailable, contributing to denominator 2 (n=1204 patients). AKI was defined as creatinine increases of ≥25% or ≥0.5 mg/dL (contrast-induced nephropathy, CIN), or ≥50% or ≥0.3 mg/dL (acute kidney injury network criteria, AKIN).
Results: By using denominator 1, the AKI incidence was 4.87% (AKIN) and 4.56% (CIN). By using denominator 2, the AKI incidence was 16.78% (AKIN) and 15.78% (CIN). There was a threefold difference of AKI incidence in the same population. Compared with those whose post-PCI creatinine unavailable, patients with post-PCI creatinine data were significantly older (63.25 vs. 68.55 years old, p< 0.001), worse baseline kidney function (estimated glomerular filtration rate 68.95 vs. 50.80 ml/min/1.73m2, p< 0.001), more comorbidities including diabetes, prior PCI, and prior heart failure, more acute myocardial infarction (AMI), and more severe in clinical conditions including acute heart failure and cardiogenic shock.
Conclusions: The AKI incidences may be biased with different denominators. Collecting pre- and post-PCI creatinine in all PCI patients is needed for accurate estimation of AKI incidence.


Biography:
Dr. Ming-Yan Jiang is a nephrologist with 6-year working experience in nephrology division of Chi Mei Medical Center. He obtained the degree of Doctor of Medicine from Kaohsiung Medical University, Taiwan. He achieved the Master Degree in Public Health from College of Medicine, National Cheng Kung University, Tainan, Taiwan. The research interests include acute kidney injury, chronic kidney disease and end stage renal disease.

VALIDITY OF MODIFIED CHARLSON COMORBIDITY INDEX AND DAVIES COMORBIDITY INDEX ON CLINICAL OUTCOMES IN INCIDENT HEMODIALYSIS AND PERITONEAL DIALYSIS

M HA1, Y KIM1, H SONG1, E CHOI1
1Bucheon Saint Mary’s Hospital,  Bucheon-city, Geoynggi-do, South Korea

Background: Comorbidity is a strong predictor of clinical outcomes in patients with end-stage renal disease (ESRD). Modified Charlson Comorbidity Index (CCI) and the Davies score predict mortality in ESRD patients and used widely in clinical practice. In this study, we compare the predictability for clinical outcomes between two comorbidity indexes in incident hemodialysis (HD) and peritoneal dialysis (PD) patients.
Methods: A total of 1,452 incident HD patients and 584 PD patients were enrolled from the Clinical Research Center registry for ESRD cohort in Korea. The CCI and Davies score were recorded at the start of dialysis and the influence on all-cause mortality were analyzed.
Results: In HD patients, the correlation between CCI and Davies score was 0.67 (p< 0.001). The Receiver Operating Characteristic (ROC) curve showed that the predictive ability for all-cause mortality of CCI (AUC 0.72, 95% CI 0.67-0.77, P<0.001) was superior to that of Davies score (AUC 0.64, 95% CI 0.59-0.69, P<0.001). In PD patients, the correlation between CCI and Davies score was 0.75 (p< 0.001). The ROC curve showed that the predictive ability for all-cause mortality of CCI (0.84, 95% CI 0.79-0.89, P<0.001) was superior to that of Davies score (0.750, 95% CI 0.67-0.83, P<0.001). The predictive ability for first hospitalization of CCI (0.838, 95% CI 0.79-0.89, P<0.001) was superior to that of Davies score (0.75, 95% CI 0.67-0.83, P<0.001).
Conclusions: Our data demonstrated that both comorbidity indexes had significant predictive power for all-cause mortality in incident HD and PD patients. And, modified CCI was stronger predictor for all-cause mortality than Davies score


Biography:
Fellowship in Bucheon Saint Mary’s Hospital

CANCER MORTALITY IN PEOPLE ON DIALYSIS IN AUSTRALIA AND NEW ZEALAND: A NATIONAL COHORT STUDY FROM 1980 TO 2013

B ROSALES1, N DE LA MATA1, P KELLY1, AC WEBSTER1,2,3
1Sydney School of Public Health, University of Sydney, , , 2Centre for Kidney Research, Sydney, NSW, , , 3Westmead Hospital, Sydney, NSW,

Aim: To compare all-site and site-specific cancer mortality between people on dialysis for end-stage kidney disease (ESKD) and the general population in Australia and New Zealand.
Background: Cancer remains a significant predictor of mortality in people on dialysis. However, people on dialysis are also at increased risk of death from other diseases. The relative risk of cancer death and any changes in cancer mortality over time are not clear.
Methods: We conducted a population-based cohort study, using ANZDATA linked with Australian and New Zealand death registries, in incident kidney transplant recipients from 1980-2013. Cancers were categorised using ICD-10-AM codes. Standardised mortality ratios (SMR) were estimated using indirect standardisation.
Results: We included 59,173 people on dialysis with 206,851 person-years (pys) of follow-up. Of 28,952 deaths, 2,640 (4.34%) were from cancer. All-site cancer mortality was 1,276 per 100,000 pys (95%CI 1229-1326), and higher in men (1474 per 100, 000 pys; 95%CI 1406-1545). People on dialysis were >2 times more likely to die cancer deaths (SMR 2.1; 95%CI 2.0-2.2) compared to the general population. All-site cancer mortality increased significantly with age in both men and women (p<0.001). The relative risk of cancer death (SMR) decreased as age increased in both men and women (p<0.001). Women were at higher risk of cancer mortality (SMR 2.4; 95%CI 2.28-2.59) than men (SMR 1.9; 1.85-2.03). Overall, all-site cancer deaths increased over time since 1980 (p<0.001), however SMRs have decreased over time (p=0.001).
Conclusions: People on dialysis are at increased risk of cancer death. Cancer mortality has increased over time, however the relative risk of cancer death, while still elevated over the general population, has decreased over time.


Biography:
Bio to come.

DIETARY INFLAMMATORY INDEX AND THE AGEING KIDNEY IN OLDER WOMEN: A 10-YEAR PROSPECTIVE COHORT STUDY

N BONDONNO1, A BIRD3,  J LEWIS2, J HODGSON4,  N SHIVAPPA6, J HÉBERT6, R WOODMAN, G WONG2,  D KERR3,  R PRINCE5, W LIM5
1University Of Western Australia, Currambine, Australia, 2Centre for Kidney Research, Children’s Hospital at Westmead. School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia, 3Curtin University, School of Public Health, Bentley , Perth, Australia, 4School of Medical and Health Sciences, Edith Cowan University, Perth, Australia, 5Sir Charles Gairdner Hospital Unit, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia, 6Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, United States of America, 7Centre for Epidemiology and Biostatistics, School of Public Health, Flinders University of South Australia, Adelaide, Australia

Aim: To examine the associations of dietary inflammatory index (DIITM), trajectory of kidney function decline and 10-year risk of chronic kidney disease (CKD)-related events (hospitalisations and/or mortality) in older Caucasian women.
Background: Chronic inflammation plays a critical role in the pathogenesis of age-related kidney disease and diet is a key moderator of systemic inflammation. Recently, the DII was devised to estimate the overall inflammatory potential of an individual’s diet, but the association between DII and kidney function decline and renal events in the general population remains unknown.
Methods: We followed up 1443 women, aged ≥70 years, from the Calcium Intake Fracture Outcome Study. The associations between DII in quintiles (an inflammatory score derived from linking 32 individual food components to inflammatory markers) and 10-year change in eGFR (at baseline, 5 and 10 years) and CKD-related events (n=123) were assessed using linear mixed modelling and Cox regression, respectively.
Results: The mean (SD) age and eGFR of the study cohort were 75.2(2.7) years and 65.9(12.9)ml/min/1.73m2, respectively. The mean(SD) annual percentage change in eGFR of women in the lowest and highest DII quintiles were -0.98(1.91) and -1.42(2.03)ml/min/1.73m2, respectively. Compared to the lowest DII quintile, the differences of least square means of the highest DII quintile was -4.97 ml/min/1.73m2  (p<0.01). Compared to the lowest DII quintile, the adjusted hazard ratio for CKD-related events for women in the highest DII quintile was 2.08(95%CI0.99,4.37, p=0.05).
Conclusion: These findings suggest that a highly pro-inflammatory diet may be associated with a more rapid kidney function decline and possibly greater risk of CKD events in older women, suggesting the consideration of integrating dietary measurements when predicting the risk of kidney function decline.


Biography:
Nicky is a Research Associate working for the University of Western Australia at Royal Perth Hospital. The primary focus of her research is looking at how polyphenols (compounds found naturally in plants, fruits and vegetables) can reduce the risk of heart disease, in particular, in patients with Chronic Kidney Disease. She hopes to show that the incidence of heart disease in Australia can be greatly reduced if we increase the intake of specific polyphenols in our diet.

ASSESSING BASELINE MEDICATION USE IN CHRONIC KIDNEY DISEASE: AN ANALYSIS OF THE SHARP-ER STUDY

MJUN1, L SUKKAR1,2, M JARDINE1, B TALBOT1, A CASS3, C REITH4, R WALKER5, M GALLAGHER1,2
1The George Institute For Global Health, Newtown, Australia, 2Sydney School of Public Health, The University of Sydney, Camperdown, Australia, 3Menzies School of Health Research, Darwin, Australia, 4Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford   , Oxford, UK, 5Dunedin School of Medicine, University of Otago, Dunedin, New Zealand

Aim:To describe baseline medication use in CKD patients of the SHARP-ER study.
Background:Medication use of patients with CKD in Australia is accepted as high, but systematic, national data has not been available. The Pharmaceutical Benefits Scheme (PBS) offers a novel means of real-world assessments medication use patterns in CKD.
Methods:Australian participants from the SHARP-ER study, a 5-year post-trial (2010-2015) extended follow-up of SHARP participants known to be alive at the end of the trial (study of cholesterol-lowering in CKD) in ANZ and Malaysia, were linked to the PBS. Prescription medication dispensation in the year prior to SHARP-ER baseline, defined as the first study visit which occurred 1.5-2 years following the final SHARP visit, were obtained. We examined medication use (receipt of ≥1 prescription) from any of the following medication groups: cardioprotective (blood pressure-lowering, lipid-lowering, glucose-lowering, anticoagulant, antiplatelet, anaemia treatment), anti-infective, immunosuppressant, proton pump inhibitor (PPI) treatment and others.
Results: Of 304 participants, 86 (28.3) were on maintenance dialysis at baseline. Overall, there were 11,272 unique prescriptions dispensed in the year prior to baseline which included those for cardioprotective(58.4%), anti-infective(9.6%), immunosuppressive(7.6%), PPI(12.6%) treatment and others(11.6%). On average, patients were prescribed 6 different medications (IQR:4-8). The distributions of medication use across the medication groups in the 304 participants were: 92.8%, 68.4%. 25.3%, 53.3% and 54.3%, respectively. The proportion of patients receiving ≥3 medication groups was significantly higher among those on dialysis (76.7% vs. 64.7%;p=0.04) compared with non-dialysis CKD patients.
Conclusions:PBS data in patients with moderate-to-severe CKD suggests a high medication burden primarily directed at cardiovascular risk mitigation. Further longitudinal assessments of cardioprotective and anti-infective medication use according to patient characteristics are needed.


Biography:
Min Jun is a Senior Research Fellow at the George Institute for Global Health and Scientia Fellow at UNSW Sydney.

HOUSING PROVISION AND HEALTH OUTCOMES AMONG NORTHERN TERRITORY HAEMODIALYSIS PATIENTS: THE DIALYSIS MODELS OF CARE PARTNERSHIP

S AHMED1, P LAWTON1, G GORHAM1, J HUGHES1, C O’HEHIR2, C FRANCIS2, T GOODHEW2,  K PRICE2, A CASS1
1Menzies School Of Health Research, Nightcliff, Australia, 2Ernst & Young, Sydney, Australia

Aim: To explore the health outcomes of dialysis patients who are tenants of urban Northern Territory government (NTG) housing.
Background: There has been little research exploring the health impacts of housing provision among dialysis patients from remote communities. The Dialysis Models of Care (DxMOC) Partnership inter-sectoral linked datasets (health to housing and education) enable the relationship between urban NT government housing tenure and health outcomes to be examined.
Methods: We used linked ANZDATA and NT hospitals data about 1360 patients receiving maintenance renal replacement therapy (RRT) between January 2000 to December 2015 inclusive, linked with urban NTG housing datasets (July 2001 to December 2015). Multivariable generalised estimating equations were used to estimate the risk of overnight hospitalisation and haemodialysis attendance for people with urban NTG housing tenancy, accounting for age, sex and Indigenous status.
Results: 222 (16.3%) RRT patients had at least one urban NTG housing allocation. 77% of them were from remote or very remote areas; 61.2% were female (p<0.05) and 94% were Indigenous (p<0.001). With multivariable analysis, tenants on haemodialysis were much less likely to have <11 haemodialysis sessions per 30 day period compared to those without urban NTG housing tenancy [odds ratio OR (95% CI), 0.55 (0.51-0.59)] The chances of overnight hospitalisation during urban NTG housing tenancy was no different for tenants compared to those without urban NTG housing tenancy [OR 0.97 (95% CI 0.91-1.04)].
Conclusions: Provision of urban public housing in the NT appears to be associated with higher haemodialysis attendance, without any difference in the chances of hospitalisation.


Biography:

Dr Paul Lawton is a kidney specialist who has been working as a clinician across the Northern Territory since 1999, including four years as Director of Northern Territory Renal Services.

In his research, he addresses questions about kidney disease care disparities and outcomes among Indigenous Australians, using larger already existing datasets, including some data linkage. How can we do better for disadvantaged populations, and why aren’t we?

IMPACT OF TYPE 2 DIABETES MELLITUS (T2DM), WITH OR WITHOUT DIABETIC NEPHROPATHY, ON CARDIOVASCULAR DISEASE (CVD) AND ALL CAUSE MORTALITY IN END-STAGE KIDNEY DISEASE PATIENTS: A POPULATION COHORT STUDY

W LIM1,2, D JOHNSON3,4,5, C HAWLEY3,4,5, C LOK6,  K POLKINGHORNE7,8,9,  M ROBERTS10,11, N BOUDVILLE1,2, G WONG12,13,14
1Sir Charles Gairdner Hospital, Perth, Australia, 2University of Western Australia, Perth, Australia, 3Princess Alexandra Hospital, Brisbane, Australia, 4University of Queensland, Brisbane, Australia, 5Translational Research Institute, Brisbane, Australia, 6University of Toronto, Toronto, Canada, 7Monash Medical Centre, Melbourne, Australia, 8Monash University – Department of Medicine, Melbourne, Australia, 9Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia, 10Eastern Health Clinical School, Monash University, Melbourne, Australia, 11Eastern Health Integrated Renal Service, Melbourne, Australia, 12University of Sydney, Sydney, Australia, 13Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia, 14Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia

Aim: To examine the association between T2DM with and without diabetic nephropathy and CVD mortality in incident dialysis patients and to determine whether this association was modified by age.
Background: The overall survival of dialysis-dependent end-stage kidney disease (ESKD) patients with T2DM may be different for those with diabetic nephropathy than those with ESKD attributed to another cause.
Methods: Using data from the ANZDATA Registry, all incident ESKD patients commencing dialysis in Australia and New Zealand between 1980-2014 were included. The association between diabetes status (i.e. no diabetes, T2DM with ESKD attributed to diabetic nephropathy or T2DM with ESKD attributed to non-diabetic nephropathy) and CVD mortality was examined using adjusted Cox regression and competing risk analyses.
Results: Of 56,552 patients followed for a median of 2.5 years (193,549 person-years), 15,829 (30.0%) and 4993 (8.8%) had T2DM with diabetic nephropathy and non-diabetic nephropathy, respectively. Compared to patients without diabetes, the adjusted hazard ratio (HR) for CVD mortality was 1.63 (95%CI 1.55-1.71) for patients with T2DM and diabetic nephropathy, and 1.31 (1.22-1.40) for patients with T2DM and non-diabetic nephropathy. There was an interaction between age and CVD mortality (pinteraction<0.001), with the excess risk of CVD mortality being greater in younger patients with T2DM and diabetic nephropathy or T2DM and non-diabetic nephropathy (age ≤30 years: 3.25 [1.87, 5.63] and 1.64 [0.71, 3.80]; >70 years: 1.24 [1.13, 1.35] and 1.21 [1.09, 1.34], respectively). Estimates from the competing risk models were similar.
Conclusions: Prevalent T2DM is associated with a survival disadvantage in incident dialysis patients, particularly younger patients, with this disadvantage more pronounced when ESKD was attributed to diabetic nephropathy as opposed to another cause.


Biography:
Consultant nephrologist

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