CLINICAL AUDIT OF URINARY TRACT INFECTIONS IN RENAL TRANSPLANT PATIENTS AT THE ROYAL BRISBANE AND WOMEN’S HOSPITAL

S OLENSKI1,2,3, C SCUDERI1,3, A CHOO1, AK BHAGAT SINGH1, M WAY4, A PELECANOS4, L JEYASEELAN5, G JOHN1
1Royal Brisbane and Women’s Hospital, Brisbane, Australia, 2Princess Alexandra Hospital, Brisbane, Australia, 3University of Queensland , Brisbane, Australia, 4QIMR Berghofer Medical Research Institute, Brisbane , Australia, 5Christian Medical College, Vellore , India

Aim: To identify the prevalence and risk factors for post-transplant urinary tract infections (UTI). To assess if UTIs affect renal function around the time of UTI and if they result in declining allograft function at 2 years.
Background: UTIs are the most common infections experienced by renal transplant recipients. The consequences of UTIs in this population are serious with increased morbidity and hospitalisation rates as well as acute allograft dysfunction. The literature is divided on whether UTIs impair overall graft and patient survival.
Methods:  This is a retrospective study of 72 patients who had a renal transplant during a 5 year period and received follow-up at the Royal Brisbane and Women’s Hospital. Patients were stratified into two groups according to the presence or absence of at least one UTI episode.
Results: Among the 72 patients who had a renal transplant, 20 (28%) had at least one UTI. Older age (p=0.015), female gender (p <0.001) and hyperglycaemia (p=0.037) were risk factors for developing a UTI. Female gender (OR 8.54), pre-existing urogenital abnormality (OR 12.96) and CMV viraemia at any time-point (OR 10.77) were statistically significant risk factors for a UTI on adjusted analysis. Serum creatinine was on average 21 points higher during a UTI episode compared to pre-UTI creatinine values (p=0.027). Serum creatinine was on average 16 points lower after a UTI episode as compared to during an episode (p=0.076). There was no significant change in serum creatinine and eGFR from baseline out to 2 years between those with and without a UTI.
Conclusions: In this cohort, UTIs acutely affected renal function during an episode however they did not impair overall renal function at 2 years.


Biography:
Dr Simon Olenski is an Advanced Trainee in Nephrology undertaking his second year of training at the Princess Alexandra Hospital. He has a diverse range of interests within Nephrology including early prevention and management of Chronic Kidney Disease, Home Therapies, Kidney Supportive Care and Clinical Leadership

A DESCRIPTIVE REVIEW OF RENAL TRANSPLANT OUTCOMES IN RECIPIENTS ≥ 70 YEARS OLD FROM 2000 TO 2015

B DOUCET1,2, S CAMPBELL1, Y CHO1, N ISBEL1,3
1Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia, 2School of Medicine, University of Queensland, Brisbane, Australia, 3University of Queensland at the Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia

Aim: To describe renal transplant outcomes of recipients ≥70 years old across Australia and New Zealand.
Background: Literature to date suggests kidney transplant in elderly recipients provides a survival benefit compared to continuing dialysis. Outcomes for transplant recipients ≥70 years in Australia and New Zealand have not been previously described. A descriptive study of kidney transplantation in elderly recipients using the ANZDATA registry was conducted.
Methods: All first graft transplant recipients from 2000-2015 registered in the ANZDATA registry were included in the study. Recipient characteristics relating to demographics, co-morbidities, graft outcomes and patient survival as well as donor-related characteristics were obtained. Transplant recipients were divided into two groups according to their age at the time of transplant (18-69years vs. ≥ 70years). Baseline characteristics and outcomes were compared using descriptive statistics and Cox proportional hazards models. P value <0.05 was considered statistically significant.
Results: Amongst the 10,651 kidney transplant recipients, 279 were elderly. Elderly recipients were more likely to have ischaemic heart disease (p<0.001), cerebrovascular disease (p<0.001), peripheral vascular disease(p=0.003), lung disease (p=0.02) and diabetes(p=0.007). Across the study period fewer elderly recipients developed rejection (19.4% vs 27.9%, p=0.002), with less rejection observed 3 months post-transplant (12.5% vs 18.0%, p=0.02). There was no difference in death censored time to graft failure (p=0.58). Across the study period, significantly more elderly recipients died (28.7% vs 13.7%, p<0.001) substantially more with functioning grafts (74.4% vs 43.2%, p<0.001).
Conclusions: Elderly patients received 2.6% of renal transplants with the majority of those occurring between 2011 to 2015. They experienced less rejection with similar graft survival compared to non-elderly recipients. Elderly recipients were more likely to die with functioning grafts.


Biography:
Brian Doucet is a second year Nephrology Advanced Trainee from Queensland. He has previously presented at the ANZSN ASM in 2014 and 2017.

TRANSCRIPTOMICS ASSOCIATION WITH ACUTE REJECTION AFTER KIDNEY TRANSPLANTATION: INTEGRATED ANALYSIS OF GENE EXPRESSION-BASED MICROARRAY DATA

Y CAO1, A LEE1, S SHAZANFAR1, S ALEXANDER2, J CRAIG2, G WONG2, J YANG3
1The University of Sydney, Camperdown, Australia, 2Centre for Kidney Research, Kids Research Institute, Westmead Hospital; College of Medicine and Public Health, Flinders University, , Australia, 3Charles Perkins Centre, The University of Sydney; School of Mathematics and Statistics, University of Sydney, Camperdown, Australia

Aim: To develop a validated set of models that identify transcriptomics-based biomarkers for predicting acute rejection after kidney transplantation.
Background: Identification of biomarkers using transcriptional profiling may allow prediction of recipients who are at risk of developing allograft injury such as acute rejection after transplantation.
Methods: Comprehensive search using Gene Expression Omnibus was conducted for publicly available datasets that contained gene expression and acute rejection data after kidney transplantation. With each selected dataset, a set of biomarkers for acute rejection was derived using five algorithms including, but not limited to XgBoost, Lasso and Random Forest. Biomarkers for each dataset are then cross-validated on the remaining independent datasets.
Results: A total of six datasets (n = 738) were included in the meta-analyses. For each dataset, a set of genes was identified for prediction of acute rejection patients within its own dataset, with optimal performance of the modeling achieved using XgBoost classifier (mean accuracy of six datasets > 84%, SD = 0.053). A set of 129 gene loci that included CXCL6, CXCL11 and OLFM4 achieved accuracy over 70% for prediction of acute rejection patients across three of the six datasets. These 129 gene loci (with 175 gene-gene interaction, based on String) were significantly enriched for genes in both the innate and cognate immune system including a significant number of molecules involved in immune trafficking such as adhesion molecules, chemokines and chemokine receptors and a number of as yet uncharacterised but intriguing zinc finger transcription factors.
Conclusions: A set of 129 gene loci with many found in immune-driven molecular pathways including adhesion, trafficking and activation achieved satisfactory performance in predicting acute rejection after kidney transplantation.


Biography:
I am currently in my Honours year of the Bachelor of Science (Advanced) degree at the University of Sydney. I double major in Molecular Biology and Genetics and Computer Science. I enjoy working with biological/clinical data, and is particularly intrigued by how programming can be utilised to discover patterns and drive solutions.

CLINICAL PROFILE, RISK FACTOR, DIAGNOSIS, TREATMENT AND OUTCOME OF POST RENAL TRANSPLANT TUBERCULOSIS FROM A SINGLE CENTRE.

K GUPTA1, S BAGAI2, A SHARMA1
1Postgraduate Institute of Medical Education and Research , Chandigarh, India, 2Max Superspeciality hospital, Saket, New Delhi, India

Background: Tuberculosis (TB) is also one of the predominant opportunistic infections post transplant.
Aims: To study the risk factors, clinical profile, treatment and outcome in post transplant TB.
Methods: Post renal transplant recipients from January 2014 and June 2017 with TB were enrolled and followed up.
Results: Sixty recipients were diagnosed with TB. Mean age was 37.97 years and mean duration of diagnosis post transplant was 44.02 months. Fever (86.7%) followed by weight loss (63%), cough with expectoration (31.7%) and breathlessness (10%) were common presentations. Extra-pulmonary 35 (58.3%) and disseminated TB 12 (20%) were more common than pulmonary TB 35 (58.3%).AFB positivity in sputum and BAL was seen in 3 (5%) and 16 (26.7%) patients whereas Trans-bronchial lung biopsy confirmed diagnosis in 6 (10 %) patients.
Lymphadenitis, 12 (20%) followed by gastrointestinal TB 8 (13.3%), pleural TB 6 (10%), spinal TB 3 (5%), TB Pericarditis 2(3.3%), CNS TB 2(3.3%), cold abscess 2(3.3%), TB osteomyelitis 1(1.6%), TB tenosynovitis 1 (1.6%) and Genitourinary TB 1 (1.6%) were pattern of involvement in extra-pulmonary TB.
Prior rejection 11 (18.3%), Anti-thymocyte Globulin use 10(16.6%), post transplant diabetes mellitus 7(11.6%), CMV 5(8.3%), HCV 4(6.6%) and HIV infection 1(1.67%) were common risk factors.
Most patients were treated for 12-18 months with non rifampicin based Antitubercular (ATT) drugs. Four (8.3%) patients had ATT induced hepatitis. 3 patients died, 2 (3%) had graft loss and 2 patients had further episodes of tuberculosis.
Conclusion: Tuberculosis is a very common opportunistic infection in post renal transplant setting in India. High index of suspicion is required for methodological work up and diagnosis.
Keywords: Tuberculosis , Extrapulmonary, Non Rifampicin Anti Tubercular Drugs.


Biography:
Dr K L Gupta is Professor of Nephrology and Head of Department at The prestigious Postgraduate Institute of Medical Education and Research at Chandigarh India. He has been serving as the faculty member since 1983. His Mai areas of interest include Fungal Infections following Renal translation as well as angio-invasive Fungal Infections of the native kidneys and Lupus Nephritis. He has been awarded many fellowship including FASN, FRCP (London) , FAMS, FISOT, FISN etc. He is currently the President of the Indian Society of Organ Transplantation and President of the Nephrology, Urology and Transplantation Society of SAARC Countries.

OUTCOME MEASURES FOR LIFE PARTICIPATION IN PATIENTS WITH KIDNEY TRANSPLANTATION

A JU1,2, M JOSEPHSON3, M HOWELL1,2, J CRAIG1,2, A TONG1,2
1The University Of Sydney, Sydney, Australia, 2Centre for Kidney Research, Westmead, Australia , 3University of Chicago Medicine, Chicago, United States

Aim: To assess the content, validity, and reliability of patient-reported outcome measures for life participation in kidney transplantation recipients.
Background: Life participation is the ability to participate in key activities of daily living including work, study, family, travel, hobbies, and recreational and social activities. It is an important outcome for kidney transplant recipients but is measured infrequently, inconsistently, and using instruments that may not be valid for this population.
Methods: We searched MEDLINE, Embase, PsycINFO, CINAHL to April 2017 for all studies that measured and reported life participation in patients with kidney transplantation. Instruments measuring life participation were identified and reviewed for psychometric properties, content and general characteristics.
Results: In total, 252 studies were included in this review: 19 (8%) randomized controlled trials, 18 (7%) non-randomized trials and 215 (85%) observational studies. Across these studies, we identified 34 different measures that were used to assess life participation. The most frequently used instrument was the 36-Item Short Form Health Survey (SF-36) (162 [64%] studies) followed by KDQOL (25 [10%] studies) and EQ-5D (15 [6%] studies). Overall, there was little evidence supporting the use of these measures in the kidney transplantation population. There was some psychometric data available for only five of the measures including SF-36, KDQOL and EQ-5D. Psychometric properties examined in these measures were inconsistent and limited.
Conclusions: Although several scales have been used to measure life participation in kidney transplant recipients, there is insufficient evidence of validity to ensure an adequate representation of their experience. A well-validated but simple instrument for life participation is needed to improve the consistency and accuracy of measurement for a better understanding and management of this important patient-centred outcome.


Biography:
PhD student working on patient-reported outcome measures for fatigue in haemodialysis and life participation in kidney transplantation

ESTABLISHING A CORE OUTCOME MEASURE FOR LIFE PARTICIPATION: A STANDARDISED OUTCOMES IN NEPHROLOGY – KIDNEY TRANSPLANTATION (SONG-TX) CONSENSUS WORKSHOP REPORT

A JU1,2, M JOSEPHSON3, S JOWSEY-GREGOIRE4, J TAN5, Q TAYLOR6, K FOWLER7, F DOBBELS8, F  CASKEY9, V JHA10, J LOCKE11, G KNOLL12, C AHN13, C HANSON1,2, K  MANERA1,2, B SAUTENET14, J CRAIG1,2, A TONG1,2
1The University Of Sydney, Sydney, Australia, 2Centre for Kidney Research, Westmead, Australia , 3University of Chicago Medicine, Chicago, United States, 4Northwestern University , Evanston, United States , 5Mayo Clinic, Rochester, United States , 6Stanford  University School of Medicine, Stanford, United States , 7Patient Family Partnership Council, Kidney Health Initiative , Chicago, United States , 8KU Leuven , Leuven, Belgium, 9University of Bristol, Bristol, United Kingdom, 10The George Institute for Global Health, Oxford, United Kingdom, 11University of Alabama, Birmingham, United States , 12The Ottawa Hospital and University of Ottawa, Ottawa, Canada , 13Seoul National University Hospital, Seoul, South Korea , 14University Francois Rabelais , Tours, France

Background: Life participation is a critically important outcome for kidney transplant recipients but it is inconsistently and infrequently measured in trials. We convened a consensus workshop on establishing a core outcome measure for life participation for use in all trials in kidney transplantation.
Methods: Twenty-five (43%) kidney transplant recipients/caregivers and 33 (57%) health professionals from eight countries participated. Transcripts were analyzed thematically.
Results: Four themes were identified. Returning to normality illustrated the patients’ desires to fulfil their given role and re-establish a normal lifestyle. Recognizing the diverse meaning of ‘life’ explicitly acknowledged life participation as a subjective outcome that may refer to different activities for different patients. Capturing fluctuations in issues post-transplant recognized the long-term impact of transplantation and emphasized the need to consider time since receiving the transplant. Having a scientifically rigorous, feasible and meaningful measure would facilitate the consistent and frequent assessment of life participation in trials.
Conclusions: A simple and inexpensive core outcome measure for life participation will allow this important outcome to be consistently and meaningfully assessed in trials in kidney transplantation to inform decision-making and care of patients


Biography:
PhD student working on patient-reported outcome measures for fatigue in haemodialysis and life participation in kidney transplantation.

ONE YEAR SURVIVAL PROGNOSTIC FACTORS OF KIDNEY TRANSPLANT RECIPIENT AT DR KARIADI GENERAL HOSPITAL, INDONESIA: SIX YEAR EXPERIENCE

M BAGIANSAH1, A NURANI2, D PARTININGRUM2, S CHASANI2,  A ARWANTO2, L LESTARININGSIH2
1Indonesian Society of Nephrology (InaSN), Semarang, Central Java, Indonesia, 2Division of Nephrology and Hypertension, Department of Internal Medicine, Diponegoro University/Dr Kariadi General Hospital, Semarang, Central Java, Indonesia

Background:Dr Kariadi General Hospital (KGH) has performed 22 kidney transplants since 2012, and keep trying to increase the quantity and quality. Data evaluating the impact of several factors on 1-year patient survival are not established yet.
Aim:This study was performed to present kidney transplantation data in KGH and aimed to identify prognostic factors associated with 1-year survival.
Methods:A retrospective cohort study on all kidney transplant patients was done from February 2012 to April 2017. Patients were follow-up until April 2018. Survival rate within 1-year were documented.
Results:18 of 22 kidney transplant recipients were included. One year survival were 61,11%. The Kaplan-Meier method revealed non-related donor (20% vs 76,92%; p=0.01), recipient’s age ≥30 years (40% vs 87.5%; p=0.04), diabetes mellitus (25% vs 76.92%; p=0.03), and hepatitis C infection (20% vs 76.92%; p=0.02) were associated with lower survival.
Conclusions:Non-related donor, recipient’s age ≥30 years at the time of transplantation, diabetes mellitus and hepatitis C infection are associated with lower 1-survival.


Biography:
Mamang Bagiansah completed Medical Doctor Degree from Padjadjaran University, Indonesia. He received his degree in Internal Medicine Specialist from Diponegoro University, Indonesia. He is currently performing his duties as a medical staff at Praya Hospital, Central Lombok, Indonesia, while preparing to enter a Nephrology and Hypertension Consultant Program. He also a member of Indonesian Society of Nephrology (InaSN). He used to spend his spare time writing poetry and traveling with his family.

 

PERITONEAL REGULATORY MACROPHAGES PROLONG ALLOGRAFT SURVIVAL IN ISLET TRANSPLANTATION

Q CAO1, C WANG1,  T CHEN1, Q LI1, V LEE1, G ZHENG1, S ALEXANDER2, Y WANG1, D HARRIS1
1Centre for Transplant and Renal Research, Westmead Institute for Medical Research, , Westmead, Australia, 2Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia

Aim and Background: Regulatory macrophages (Mreg) are highly versatile effector cells which have become a valuable source of cell therapy for clinical transplantation. In this study, we examined the potential of using Mreg induced from peritoneal mononuclear phagocytes to promote transplanted islet survival and function in diabetic mice.
Methods: Peritoneal macrophages separated from a murine peritoneal dialysis model were polarized to Mreg by incubating with M-CSF and IFN-γ. Mreg were given at day 1, 3 and 7 after islet transplantation in STZ-induced diabetic mice. Islet function (blood glucose and IP-GTT) and T cell responses were measured to assess the effect of Mreg.
Results: In vivo, Mreg significantly improved diabetic control and islet survival after islet transplantation in diabetic mice. Blood glucose was normal for 30 days post transplantation following Mreg treatment. The number of insulin positive cells in islet allograft of transplanted mice treated with Mreg was significantly higher than that in transplanted mice without Mreg. The numbers of CD4+ and CD8+ T cells in islet allografts were significantly reduced in transplanted mice by treatment with Mreg. The percentages of CD4+ and CD8+ T cells in the blood and spleen of transplanted mice were significantly lower with Mreg treatment. In vitro, Mreg suppressed CD4+ and CD8+ T cell proliferation, and reduced CD25 and CD69 expression by both CD4+ and CD8+ T cells. Mreg also promoted CD4+ and CD8+ T cell apoptosis.
Conclusion: This study demonstrates that peritoneal regulatory macrophages prolong allograft survival in islet transplantation, probably through suppression of CD4+ and CD8+ T cell activation and proliferation.


Biography:
Dr. Qi Cao works as a senior research fellow in Centre for Transplant and Renal Research, Westmead Institute for Medical Research at University of Sydney. His recent focus has been on the role of renal mononuclear phagocytes in chronic kidney diseases (CKD) and their therapeutic potential for CKD.

INFECTION-RELATED MORTALITY FOLLOWING KIDNEY TRANSPLANTATION IN AUSTRALIA AND NEW ZEALAND

S CHAN1,2,3, E PASCOE1,2,3, P CLAYTON1,4,5, S MCDONALD1,4,5, W LIM1,6, M SYPEK1,4,5, S PALMER7, R FRANCIS2,3, S CAMPBELL1,2,3, C HAWLEY1,2,3, D JOHNSON1,2,3
1Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia, 2Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia, 3Australasian Kidney Trials Network, Faculty of Medicine, The University of Queensland, Brisbane, Australia, 4Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia, 5School of Medicine, University of Adelaide, Adelaide, Australia, 6Sir Charles Gairdner Hospital Unit, The University of Western Australia, Perth, Australia, 7Department of Medicine, University of Otago, Christchurch, New Zealand

Aim: To examine the aetiology and predictors of infection-related mortality among kidney transplant recipients in Australia and New Zealand.
Background: Infections following kidney transplantation are associated with significant morbidity and mortality. However, there has been limited study regarding the burden and risk factors for infection-related mortality in kidney transplant recipients.
Methods: This study included all Australian and New Zealand kidney transplant recipients who had a first graft between January 1, 1997 and December 31, 2015, using Australia and New Zealand Dialysis and Transplant Registry data. Infection-related mortality was evaluated by multivariable competing risk regression with non-infectious mortality as the competing risk.
Results: A total of 12,519 kidney transplant recipients were included (median age (IQR) 46 (36-55)yrs, males 63%, diabetes 15%, Indigenous 6%). Of the 2,197 deaths, 416 (19%) were infectious and of these, 224 (54%) were bacterial. Higher infectious mortality was associated with older age (20-30yrs reference; ≥60yrs subdistribution hazard ratio (SHR) 3.98, 95% CI 1.98-8.02), female gender (SHR 1.56, 95% CI 1.17-2.15), indigenous ethnicity (SHR 3.33, 95% CI 2.09-5.29, compared with Caucasian ethnicity), earlier transplant era (1997-2005 reference; 2006-2015 SHR 0.56, 95% CI 0.31-0.84), and use of thymoglobulin/ OKT3 for both induction therapy and treatment of rejection (daclizumab/ basiliximab reference; SHR 2.18, 95% CI 1.47-3.23). Polycystic kidney disease was associated with a lower hazard of infectious mortality (glomerulonephritis reference; SHR 0.52, 95% CI 0.28-0.99). There was no association between infectious mortality and donor characteristics.
Conclusions: Older age, female gender, indigenous ethnicity, earlier transplant era and use of T-cell depleting therapy are associated with increased infectious mortality following kidney transplantation. Bacterial infections are the commonest cause of infectious death in transplant recipients.


Biography:
Dr Samuel Chan is a final year nephrology advanced trainee working for Queensland Health. He has also commenced his PhD with the Department of Nephrology and the Australasian Kidney Trials Network at the Princess Alexandra Hospital in Brisbane, Queensland. Dr Chan’s studies will be centred around infectious complications following kidney transplantation.

INTERVENTIONS FOR NON-MELANOMA SKIN CANCERS IN RECIPIENTS OF A SOLID-ORGAN TRANSPLANT: A META-ANALYSIS OF RANDOMISED TRIALS

E CHUNG1,S PALMER2, G STRIPPOLI3,4,5,6
1Royal North Shore Hospital, Sydney, Australia, 2University of Otago , Christchurch, New Zealand, 3University of Sydney, Sydney , Australia, 4Cochrane Kidney and Transplant, Westmead, Australia, 5University of Bari, Bari, Italy, 6Medical Scientific Office and Diaverum Academy, Diaverum, Sweden

Aim: We did a systematic review with meta-analysis to summarise the benefits and harms of interventions used to prevent non-melanoma skin cancer following solid organ transplantation and to evaluate the certainty of the available evidence.
Background: Organ transplant recipients have a much higher risk of developing skin cancer than the general population.
Methods: We searched MEDLINE, Embase and CENTRAL through to 16 December 2017 for randomised controlled trials evaluating interventions to prevent non-melanoma skin cancer in organ transplant recipients. One author independently selected eligible studies and extracted data. Risk of bias were assessed using the Cochrane tool and evidence certainty was evaluated using the GRADE process. Outcomes were non-melanoma skin cancer, keratotic skin lesions, the Standardised Outcomes in Nephrology-transplant core outcomes (graft function, all-cause mortality, cardiovascular events, infection, life participation) and intervention-specific adverse events.
Results: Fourteen trials (420 participants) met eligibility criteria. Compared to placebo or no treatment, any intervention (acitretin, imiquimod, nicotinamide [2 trials, 60 participants, relative risk (RR) 0.67, 95% confidence interval (CI) 0.05-8.87], or photodynamic therapy [3 trials, 93 participants, RR 1.40, CI 0.65-3.02]) had uncertain effects on risk of non-melanoma skin cancers. Effects of any intervention on graft function were uncertain though most trials were not designed to assess treatment effects on graft function, all-cause mortality, cardiovascular events, infection or life participation.  Moderate-quality evidence indicated imiquimod did not reduce mortality (2 trials, 63 participants, RR 0.67, CI 0.05-8.87). In low-quality evidence, photodynamic therapy may prevent keratotic skin lesions (2 trials, 53 participants, RR 0.24, CI 0.12-0.48).
Conclusions: It is uncertain whether any intervention prevents non-melanoma skin cancers among solid organ transplant recipients or impacts graft function.


Biography:
Edmund Chung is currently a first year renal advanced trainee in the East Coast Network, NSW. He completed his undergraduate BMed MD at UNSW and postgraduate MMed (ClinEpi) at the University of Sydney. He has performed systematic reviews with the Cochrane Kidney and Transplant group and is passionate about better understanding how to limit the progression of chronic kidney disease.

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