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1. Arrhythmia and Time of Day in Maintenance Hemodialysis: Secondary Analysis of the Monitoring in Dialysis Study

Author

Qandeel H. Soomro, Bruce A. Koplan, Alexandru I. Costea, Prabir Roy-Chaudhury, James A. Tumlin, Vijay Kher, Don E. Williamson, Saurabh Pokhariyal, Candace K. McClure, David M. Charytan, Don Williamson, James Tumlin, Vikranth Reddy, Kowdle Chandrasekhar Prakash, David Charytan, Suresh Chandra Tiwari, Amber Podoll, Sanjeev Jasuja, G. Leslie Walters, Kraig Wangsnes, Alexandru Costea, Selcuk Tombul, Balbir Singh, Brajesh Mishra, Sachin Yalagudri, Abhijeet Shelke, Calambur Narasimhan, A.M. Karthigesan, Abraham Oomman, K.P. Pramod Kumar, Bruce Koplan, Upendra Kaul, Tapan Ghose, Ripen Gupta, Arvind Sethi, Nikhil Kumar, Ramesh Hariharan, Rajnish Sardana, Arif Wahab, N.N. Khanna, Mark Smith, Suresh Kamath, Claude Galphin, Puneet Sodhi, Rajsekara Chakravarthy, Subba Rao Budithi, Finnian McCausland, Sanjeev Gulati, Munawer Dijoo, Upendra Singh, Salil Jain, Vishal Saxena, Gaurav Sagar, Rachel Fissell, Robert Foley, Charles A. Herzog, Peter McCullough, John D. Rogers, Peter Zimetbaum, Manish Assar, Mark Kremers, and Wolfgang C. Winkelmayer

Subjects
Arrhythmia, atrial fibrillation, bradycardia, circadian rhythm, dialysis, end-stage kidney disease, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Rationale & Objective: The incidence of arrhythmia varies by time of day. How this affects individuals on maintenance dialysis is uncertain. Our objective was to quantify the relationship of arrhythmia with the time of day and timing of dialysis. Study Design: Secondary analysis of the Monitoring in Dialysis study, a multicenter prospective cohort study. Settings & Participants: Loop recorders were implanted for continuous cardiac monitoring in 66 participants on maintenance dialysis with a follow up of 6 months. Exposure: Time of day based on 6-hour intervals. Outcomes: Event rates of clinically significant arrhythmia. Analytical Approach: Negative binomial mixed effects regression models for repeated measures were used to evaluate data from the Monitoring in Dialysis study for differences in diurnal patterns of clinically significant arrhythmia among those with end-stage kidney disease with heart failure and end-stage kidney disease alone. We additionally analyzed rates according to presence of heart failure, time of dialysis shift, and dialysis versus nondialysis day. Results: Rates of clinically significant arrhythmia peaked between 12:00 AM and 5:59 AM and were more than 1.5-fold as frequent during this interval than the rest of the day. In contrast, variations in atrial fibrillation peaked between 6:00 AM and 11:59 AM, but variations across the day were qualitatively small. Clinically significant arrhythmia occurred at numerically higher rate in individuals with end-stage kidney disease and heart failure (5.9 events/mo; 95% CI, 1.3-26.8) than those without heart failure (4.0 events/mo; 95% CI, 0.9-17.9). Although differences in overall rate were not significant, their periodicity was significantly different (P

Published
2024
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2. Renal Transplantation in Patients With Tuberculosis: A Single-center Experience From an Endemic Region

Author

Ashwini B. Gadde, MD, DNB, Pranaw Kumar Jha, MD, DNB, Shyam B. Bansal, MD, DM, Abhyudaysingh Rana, MD, DNB, Manish Jain, MD, DM, Dinesh Bansal, MD, DM, Dinesh Kumar Yadav, MD, DM, Amit Kumar Mahapatra, MD, DM, Sidharth Kumar Sethi, MD, FASN, and Vijay Kher, MD, DM

Subjects
Surgery, RD1-811
Abstract

Background. Despite being a common infection in end-stage kidney disease patients, there are no evidence-based guidelines to suggest the ideal time of transplantation in patients on antitubercular therapy (ATT). This study aimed to examine the outcome of transplantation in patients while on ATT compared with those without tuberculosis (TB). Methods. This was a retrospective study. Renal transplant recipients transplanted while on ATT were compared with a 1:1 matched group (for age, sex, diabetic status, and type of induction agent) of patients without TB at the time of transplant. Patient outcomes included relapse of TB and graft and patient survival. Results. There were 71 patients in each group. The mean duration for which ATT was given pretransplant was 3.8 ± 2.47 mo. The average total duration of ATT received was 12.27 ± 1.25 mo. Mortality in both the groups was similar (8.4% in the TB group versus 4.5% in the non-TB group; P = 0.49). None of the surviving patients had recurrence of TB during the follow-up. Death-censored graft survival (98.5% in the TB group versus 97% in the non-TB group; P = 1) and biopsy-proven acute rejection rates (9.86% in the TB group versus 8.45% in the non-TB group; P = 1) were also similar in both the groups. Conclusions. Successful transplantation in patients with end-stage kidney disease on ATT is possible without any deleterious effect on patient and graft survival and no risk of disease recurrence. Multicentric prospective studies are needed.

Published
2023
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3. Implantable Loop Recorder Monitoring and the Incidence of Previously Unrecognized Atrial Fibrillation in Patients on Hemodialysis

Author

Bruce A. Koplan, Wolfgang C. Winkelmayer, Alexandru I. Costea, Prabir Roy-Chaudhury, James A. Tumlin, Vijay Kher, Don E. Williamson, Saurabh Pokhariyal, David M. Charytan, Don Williamson, MD, Prabir Roy-Chaudhury, MD, James Tumlin, MD, Vijay Kher, MD, Vikranth Reddy, MD, Kowdle Chandrasekhar Prakash, MD, David Charytan, MD MSc, Suresh Chandra Tiwari, MD, Saurabh Pokhariyal, MD, Amber Podoll, MD, Sanjeev Jasuja, MD, G. Leslie Walters, MD, Kraig Wangsnes, MD, Alexandru Costea, MD, Selcuk Tombul, MD, Balbir Singh, MD, Brajesh Mishra, MD, Sachin Yalagudri, MD, Abhijeet Shelke, MD, Calambur Narasimhan, MD, A.M. Karthigesan, MD, Abraham Oomman, MD, K P Pramod Kumar, MD, Bruce Koplan, MD, Upendra Kaul, MD, Tapan Ghose, MD, Ripen Gupta, MD, Arvind Sethi, MD, Nikhil Kumar, MD, Ramesh Hariharan, MD, Rajnish Sardana, MD, Arif Wahab, MD, N.N. Khanna, MD, Mark Smith, MD, Suresh Kamath, MD, Claude Galphin, MD, Puneet Sodhi, MD, Rajsekara Chakravarthy, MD, Subba Rao Budithi, MD, Finnian McCausland, MB, MMSc, Sanjeev Gulati, MD, Munawer Dijoo, MD, Upendra Singh, MD, Salil Jain, MD, Vishal Saxena, MD, Gaurav Sagar, MD, David Charytan, MD, MSc, Rachel Fissell, MD, Robert Foley, MD, Charles A. Herzog, MD, Peter A. McCullough, MD, John D. Rogers, MD, James A. Tumlin, MD, Peter Zimetbaum, MD, Manish Assar, MD, Mark Kremers, MD, and Wolfgang C. Winkelmayer, MD, ScD

Subjects
arrhythmias, atrial fibrillation, hemodialysis, kidney failure, end stage kidney diseae (ESKD), implantable loop recorder, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Introduction: Atrial fibrillation (AF) is common in patients with kidney failure on hemodialysis (KF-HD). We determined both AF incidence and burden in patients with KF-HD using implantable loop recorder (ILR) monitoring. Methods: Patients with KF-HD were enrolled and received an ILR. In 6 monitoring months, the incidence of AF events lasting ≥6 minutes was captured. Demographic, clinical, and dialysis characteristics were collected, and associations with incident AF were estimated using negative binomial regression models and expressed as incidence rate ratios and 95% CIs. Results: We enrolled 66 patients with KF-HD (mean age = 56 years, 70% male); 59 (90%) were without previously diagnosed AF. AF lasting ≥6 minutes was detected in 18 of 59 subjects (31%) without previously diagnosed AF and in 5 of 7 subjects (71%) with a previous AF diagnosis. Among the 23 with detected AF, episodes were present on 16% of patient days. Although 14 of 23 patients (61%) had AF on 2.5 vs. 2.5 mEq/l: incidence rate ratio = 0.62; 95% CI, 0.48–0.80) was associated with lower AF risk whereas higher dialysate bicarbonate concentrations (>35 vs. 35 mEq/l: incidence rate ratio = 3.18; 95% CI, 1.13–8.94) were associated with higher AF risk. Conclusion: New AF was detected in approximately one-third of patients with KF-HD. AF affects a substantial proportion of patient days and may be an underappreciated cause of stroke in KF-HD.

Published
2022
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4. Treatment and Outcomes of Coronavirus Disease 2019 in Kidney Transplant Recipients: A Single-center Experience

Author

Shyam Bihari Bansal, Mayur Babras, Abhyuday Rana, Ashwini Gadde, Pranaw Jha, Manish Jain, Dinesh Yadav, Dinesh Bansal, Sidharth Sethi, and Vijay Kher

Subjects
Medicine
Abstract

There is a paucity of literature about the outcomes of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 after kidney transplantation in developing countries (e.g., India). We included 50 consecutive kidney transplant recipients diagnosed with COVID-19 from August 2020 to December 2020. The mean age was 50 ± 10 years, and the median interval since transplantation was 34 months. Fever (100%), cough (40%), and shortness of breath (32%) were the most common presenting symptoms. Mild disease occurred in 26 patients, moderate disease in 12, and severe disease in 12. All 24 patients with moderate-to-severe disease received remdesivir and high-dose steroids, whereas 17 of 26 patients with mild disease received favipiravir. Convalescent plasma was given to 13 of 24 patients with moderate-to-severe disease, and 7 of 12 patients with severe disease received tocilizumab. The median hospital stay was 7 days (interquartile range: 4–20 days). Of 30 patients who developed acute kidney injury, seven required renal replacement therapy and eight required mechanical ventilation. Eight patients with severe disease died. An age of >50 years, coughing, shortness of breath at presentation, C-reactive protein levels of >100 mg/dL, D-dimer levels of >1 mg/L, computed tomography severity scores of >20 at presentation, supplemental oxygen, and mechanical ventilation correlated significantly with mortality in our cohort. COVID-19 infection in kidney transplant recipients had a high mortality rate; however, remdesivir and high-dose steroids were associated with better outcomes compared with earlier studies.

Published
2022
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5. Preparing for transplant - Screening and prophylaxis of donor and recipients before solid organ transplantation: Expert group opinion from South Asia

Author

Shyam Bihari Bansal, Vijay Kher, Venkatasubramanian Ramsubramanian, Narendra S Choudhary, and Camille Nelson Kotton

Subjects
donor, endemic, infection, recipient, screening, south asia, transplant, Surgery, RD1-811
Abstract

Infections are major cause of morbidity and mortality after transplantation. Although many infections are common worldwide, there are differences in various geographic locations. South Asia and India, in particular, has a very active transplant program for kidney and liver transplantation, however, there are no guidelines as how to screen and provide prophylaxis to solid organ transplant (SOT) recipients and donors for both specific infections prevalent in this region along with usual infections. Keeping this in mind, a working group was created comprising transplant physicians, surgeons, and infectious disease specialists from South Asia as well as experts from other countries. This working group developed guidelines based on published evidence, unpublished data from large centers in this region, along with expert opinion. This section of the guidelines deals with pretransplant screening of donors and recipients, which should be useful in dealing with transplants performed in this region for patients belonging to these countries, for those coming for transplantation from other countries, and for programs outside of South Asia who are screening donors and recipients from this region or who have spent significant time in this region.

Published
2022
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6. Clinical perspectives towards improving risk stratification strategy for renal transplantation outcomes in Indian patients

Author

Vijay Kher, Vivek B Kute, Sarbeswar Sahariah, Deepak S Ray, Dinesh Khullar, Sandeep Guleria, Shyam Bansal, Sishir Gang, Anil Kumar Bhalla, Jai Prakash, Abi Abraham, Sunil Shroff, Madan M Bahadur, Pratik Das, Urmila Anandh, Arpita Ray Chaudhury, Manoj Singhal, Jatin Kothari, Sree Bhushan Raju, Dilip Kumar Pahari, G Vishwanath Siddini, G Sudhakar, Santosh Varughese, and Tarun K Saha

Subjects
acute rejection, donor-specific antibody, human leukocyte antigens, immunosuppression, indian patients, living donors, renal transplantation, Surgery, RD1-811
Abstract

Graft loss and rejections (acute/chronic) continue to remain important concerns in long-term outcomes in kidney transplant despite newer immunosuppressive regimens and increased use of induction agents. Global guidelines identify the risk factors and suggest a framework for management of patients at different risk levels for rejection; however, these are better applicable to deceased donor transplants. Their applicability in Indian scenario (predominantly live donor program) could be a matter of debate. Therefore, a panel of experts discussed the current clinical practice and adaptability of global recommendations to Indian settings. They also took a survey to define risk factors in kidney transplants and provide direction toward evidence- and clinical experience-based risk stratification for donor/recipient and transplant-related characteristics, with a focus on living donor transplantations. Several recipient related factors (dialysis, comorbidities, and age, donor-specific antibodies [DSAs]), donor-related factors (age, body mass index, type – living or deceased) and transplantation related factors (cold ischemia time [CIT], number of transplantations) were assessed. The experts suggested that immunological conflict should be avoided by performing cytotoxic cross match, flow cross match in all patients and DSA-(single antigen bead) whenever considered clinically relevant. HLA mismatches, presence of DSA, along with donor/recipient age, CIT, etc., were associated with increased risk of rejection. Furthermore, the panel agreed that the risk of rejection in living donor transplant is not dissimilar to deceased donor recipients. The experts also suggested that induction immunosuppression could be individualized based on the risk stratification.

Published
2022
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7. Evaluation of screening tests for pre-transplant compatibility testing in live-related kidney transplants: Single-center report from India - A prospective observational study

Author

Rajni Chauhan, Aseem Kumar Tiwari, Chhavi Rajvanshi, Simmi Mehra, Geet Aggarwal, Shyam Bihari Bansal, and Vijay Kher

Subjects
compatibility, live-related, pre-transplant, renal transplant, single-antigen bead, Surgery, RD1-811
Abstract

Introduction: Pre-transplant compatibility testing involves the use of different methodologies (cell-based and solid phase based) for the determination of anti-human-leukocyte antigen (HLA) antibodies. Implementation of these donor-recipient methods in the screening of patients awaiting transplantation increased their chance of successful graft and patient outcomes. Materials and Methods: A total of 1054 patients visiting tertiary care hospitals for pretransplant compatibility testing were screened with cell-based tests; complement-dependent cytotoxicity crossmatch (CDC-XM) and flow cytometric crossmatch (FC-XM). The patients positive for either or both screening tests were suspected to have anti-HLA antibodies. Luminex single-antigen bead (SAB) tests were performed in such patients to determine and identify antibody specificity and establish donor-specific antibody (DSA). Results: The study showed a significantly higher sensitivity of the FCXM (94.6%) method when compared with CDC-XM (35.7%), considering the SAB assay as the gold standard technique. The specificity of CDC-XM (100%) was slightly higher than the FC-XM (76.3%). Combination of FC-XM with CDC-XM (17 cases) was 100% sensitive and specific to identify DSA (s). The graft-survival was 94.77% using the proposed algorithm. Conclusions: The combination of CDC-XM and FC-XM, along with SAB assay, could be used as a screening algorithm as it is a useful technique in identifying the specificities of alloantibodies, assessment of DSAs. Hence, the presented algorithm can become a new standard for the identification of potential recipients awaiting kidney transplantation in India.

Published
2021
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8. Current Status and Future of End-Stage Kidney Disease in Gulf Cooperation Council Countries: Challenges and Opportunities

Author

Tushar Vachharajani, Sanjiv Jasuja, Ali AlSahow, Saeed M G. Alghamdi, Ali H Al-Aradi, Issa Al Salmi, Bassam Bernieh, Yousif Bahbahani, Fadwa Alali, Raja Ramachandran, Suceena Alexander, Sandeep K Mandal, Rajeev K Malhotra, Manisha Sahay, Vinant Bhargava, Vivekanand Jha, Devendra Singh Rana, Gaurav Sagar, Anupam Bahl, Vijay Kher, Narayan Prasad, Krishnaswamy S Kumar, Mona Alrukhaimi, Gloria E Ashuntantang, Shalini Verma, and Maurizio Gallieni

Subjects
Medicine
Abstract

There is a paucity of data on epidemiology along with an incomplete registry of end-stage kidney disease (ESKD), nephrologist workforce, and variability among the countries of Gulf Cooperation Council (GCC). The study is an observation, descriptive study which aimed to describe current ESKD burden, nephrologist density, and kidney care infrastructure in GCC. Responses to a questionnaire-based survey obtained from representatives of the Nephrology Societies of GCC countries were analyzed. The categorical variables were compared using Chi-square test. A P = 5% was considered as significant. The mean prevalence of ESKD per million populations (pmp) was 551, highest in Oman (1000/pmp), least in Qatar (347/pmp). Predominant etiology in GCC was diabetes mellitus (DM) and hypertension (HTN) (100%, each), followed by chronic glomerulonephritis (66.7%). A transplant registry was maintained by all GCC countries. Hemodialysis (HD) (67.2%) was the most opted modality of kidney replacement therapy (KRT), followed by kidney transplantation (22%) and peritoneal dialysis (9.6%); 1.0% of patients opted for conservative management. Unplanned initiation of HD was three times more common. The access distribution among incident and prevalent HD patients respectively was (i) nontunneled central catheter (nTCC) (58.7 ± 36.6 vs. 1.5 ± 1.5), (ii) tunneled central catheter (23.5 ± 29.9 vs. 33.6 ± 10.0), and (iii) arteriovenous fistula (17.3± 14.4 vs. 57.8 ± 11.86). Death and transplantation were the reasons for dropout from HD. GCC has adequate kidney care infrastructure. There are 1686 nephrologists [range: Bahrain 9, Kingdom of Saudi Arabia (KSA) 1279]. Qatar, KSA, and Kuwait provide training in kidney biopsy; all countries except Bahrain have formal training programs for nTCC placement. ESKD prevalence is high, DM, HTN; glome-rulonephritis (GN) is the most common causes. The need for KRT is expected to rise in GCC. HD is the predominant KRT modality with a high prevalence of dialysis catheters as vascular access.

Published
2021
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9. Management strategies and outcomes in renal transplant recipients recovering from COVID-19: A retrospective, multicentre, cohort study

Author

Vivek B. Kute, Deepak S. Ray, Feroz Aziz, Suraj M. Godara, Umapati Hegde, Anil KumarBT, Anil K. Bhalla, Dinesh Kumar Yadav, Sarbpreet Singh, Vivek Pathak, Sonal Dalal, Madan M. Bahadur, Urmila Anandh, Abi Abraham M, Vishwanath Siddini, Sushree Sashmita Das, Sharmila Thukral, Arvind Krishnakumar, Ashish Sharma, Vijay Kher, Shyam B. Bansal, Ashay Shingare, Ranjit Narayanan, Himanshu Patel, Sanjeev Gulati, Shailesh Kakde, Dinesh Bansal, Sandeep Guleria, Dinesh Khullar, Manoj R. Gumber, Umesh Varyani, Swarnalatha Guditi, Prakash Khetan, Rutul Dave, Vineet V. Mishra, Stefan G. Tullius, Sanshriti Chauhan, and Hari Shankar Meshram

Subjects
SARS-CoV-2, Kidney transplantation, Post-COVID-19, Induction immunosuppression, Medicine (General), R5-920
Abstract

Summary: Background: There is an enormous knowledge gap on management strategies, clinical outcomes, and follow-up after kidney transplantation (KT) in recipients that have recovered from coronavirus disease (COVID-19). Methods: We conducted a multi-center, retrospective analysis in 23 Indian transplant centres between June 26, 2020 to December 1, 2021 on KT recipients who recovered after COVID-19 infections. We analyzed clinical and biopsy-confirmed acute rejection (AR) incidence and used cox-proportional modeling to estimate multivariate-adjusted hazard ratios (HR) for predictors of AR. We also performed competing risk analysis. Additional outcome measures included graft loss, all-cause mortality, waiting time from a positive real-time polymerase test (RT-PCR) to KT, laboratory parameters, and quality of life in follow-up. Findings: Among 372 KT which included 38(10·21%) ABO-incompatible, 12(3·22%) sensitized, 64(17·20%) coexisting donors with COVID-19 history and 20 (5·37%) recipients with residual radiographic abnormalities, the incidence of AR was 34 (9·1%) with 1(0·26%) death censored graft loss, and 4(1·07%) all-cause mortality over a median (interquartile range) follow-up of 241 (106–350) days. In our cox hazard proportional analysis, absence of oxygen requirement during COVID-19 compared to oxygen need [HR = 0·14(0·03–0·59); p-value = 0·0071], and use of thymoglobulin use compared to other induction strategies [HR = 0·17(0·03–0.95); p-value = 0·044] had a lower risk for AR. Degree of Human leukocyte antigen (HLA) DR mismatch had the highest risk of AR [HR = 10.2(1·74–65·83); p-value = 0·011]. With competing risk analysis, with death as a competing event, HLA DR mismatch, and oxygen requirement continued to be associated with AR. Age, gender, obesity, inflammatory markers, dialysis vintage, steroid use, sensitization and ABO-incompatibility have not been associated with a higher risk of AR. The median duration between COVID-19 real time polymerase test negativity to transplant was 88(40–145) days (overall), and ranged from 88(40–137), 65(42–120), 110(49–190), and 127(64–161) days in World Health Organization ordinal scale ≤ 3, 4, 5, and 6–7, respectively. There was no difference in quality of life, tacrolimus levels, blood counts, and mean serum creatinine assessed in patients with a past COVID-19 infection independent of severity. Interpretation: Our findings support that the outcomes of KT after COVID-19 recovery are excellent with absence of COVID-19 sequelae during follow-up. Additionally, there does not seem to be a need for changes in the induction/immunosuppression regimen based on the severity of COVID-19. Funding: Sanofi

Published
2022
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10. Impact of COVID-19-associated Mucormycosis in Kidney Transplant Recipients: A Multicenter Cohort Study.

Author

Hari Shankar Meshram, MD, DM, Vivek B. Kute, MD, DM, FASN, FRCP, Dinesh Kumar Yadav, MD, DM, Suraj Godara, MD, DM, Sonal Dalal, MD, DNB, Sandeep Guleria, MS, DNB, FRCS, FRCP, Anil K. Bhalla, MD, DM, FASN, FRCP, Vivek Pathak, MD, DNB, Urmila Anandh, MD, DM, DNB, FASN, FRCP, Shyam Bansal, MD, DM, FRCP, Himanshu Patel, MD, DNB, FRCP, Umapati Hegde, MD, DNB, Ruchir Dave, MD, Sanshriti Chauhan, MD, Rutul Dave, MD, DM, Deepak Kumar, MD, DM, Tukaram Jamale, MD, DM, Divya Bajpai, MD, DM, Deepesh Kenwar, MS, Keshab Sil, MD, DM, Harsh Vardhan, MD, DM, FASN, Manish Balwani, MD, DM, Mayur Patil, MD, DM, Rushi Deshpande, MD, DNB, DM, Ashish Nandwani, MD, DNB, FASN, Pranaw Kumar Jha, MD, DNB, Manish Jain, MD, DM, Pratik Das, MD, DNB, DM, FASN, Vineet Mishra, MD, FRCP, Dorry L. Segev, MD, PhD, and Vijay Kher, MD, DNB, DM

Subjects
Surgery, RD1-811
Abstract

Background. COVID-19-associated mucormycosis (CAM) is a recently emerging entity. There is a lack of reports of CAM in organ transplant recipients. Methods. We conducted a multicenter (n = 18) retrospective research in India during November 2020 to July 2021. The purpose of this study was to explore the clinical spectrum, outcome and risk factors for mortality of CAM in kidney transplant recipients (KTRs). Results. The incidence of CAM was 4.4% (61/1382 COVID-19-positive KTRs) with 26.2% mortality. The median age of the cohort was 45 (38–54) y. Twenty (32%) were not hospitalized and 14 (22.9%) were on room air during COVID-19. The proportion of postdischarge CAM was 59.1%, while concurrent CAM was reported in 40.9%. The presentation of CAM was 91.8% rhino-orbital-cerebral mucormycosis and 8.2% pulmonary with 19.6% and 100% mortality, respectively. In the univariable analysis, older age, obesity, difficulty of breathing, high-flow oxygen requirement, and delay in starting therapy were significantly associated with mortality. In the multivariable logistic regression analysis, patients requiring high-flow oxygen therapy [odds ratio (95% confidence interval) = 9.3 (1.6-51); P = 0.01] and obesity [odds ratio (95% confidence interval) = 5.2 (1-28); P = 0.05] was associated with mortality. The median follow-up of the study was 60 (35–60) d. Conclusions. We describe the largest case series of CAM in KTRs. Morality in pulmonary CAM is extremely high. Severe COVID-19 pose extra risk for the development of CAM and associated mortality. Our report will help in better understanding the conundrum and management of CAM.

Published
2022
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11. A case report of ABO and human leukocyte antigen incompatible renal transplant – Being immunologically smart

Author

Pranaw Kumar Jha, Ajay Kher, and Vijay Kher

Subjects
blood group incompatibility, desensitization, human leukocyte antigen incompatible, kidney transplantation, Surgery, RD1-811
Abstract

Blood group and human leukocyte antigen (HLA) incompatibility are major immunological barriers in renal transplantation. Desensitization and subsequent transplantation improve the longevity and quality of life of these patients when compared to being on a waitlist. For best outcomes, a complete repertoire of immunological workup and an in-depth understanding of these tests are important for choosing the most suitable donor against whom the recipient is least sensitized. We present an interesting case of a sensitized patient who had the option of undergoing renal transplant with either a blood group incompatible mother or a compatible aunt as the prospective donor. Despite the blood group incompatibility, the mother was chosen as the donor in view of the lower strength of anti-HLA antibodies against her. The patient had a successful posttransplant outcome with good graft function at 1 year follow-up. Careful donor selection after detailed immunological workup is important while transplanting sensitized recipients. HLA incompatibility rather than blood group incompatibility should be the deciding factor in such cases.

Published
2020
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13. Study to Test and Operationalize Preventive Approaches for CKD of Undetermined Etiology in Andhra Pradesh, India

Author

Oommen John, Balaji Gummidi, Abha Tewari, J.P. Muliyil, Arpita Ghosh, Meena Sehgal, Abhinav Bassi, Shankar Prinja, Vivek Kumar, Om P. Kalra, Vijay Kher, J.S. Thakur, Lakshmy Ramakrishnan, C.M. Pandey, V. Sivakumar, R.S. Dhaliwal, Tripti Khanna, Aruna Kumari, Jitender Sharma, Poonam Malakondiah, and Vivekanand Jha

Subjects
Diseases of the genitourinary system. Urology, RC870-923
Abstract

Introduction: High prevalence of chronic kidney disease (CKD) not associated with known risk factors has been reported from coastal districts of Andhra Pradesh. The Study to Test and Operationalize Preventive Approaches for Chronic Kidney Disease of Undetermined Etiology in Andhra Pradesh (STOP CKDu AP) aims to ascertain the burden (prevalence and incidence) of CKD, the risk factor profile, and the community perceptions about the disease in the Uddanam area of Andhra Pradesh. Methods: Study participants will be sampled from the Uddanam area using multistage cluster random sampling. Information will be collected on the demographic profile, occupational history, and presence of conventional as well as nonconventional risk factors. Glomerular filtration rate (GFR) will be estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and proteinuria will be measured. All abnormal values will be confirmed by repeat testing after 3 months. Cases of CKD not associated with identified etiologies will be identified. Biospecimens will be stored to explore future hypotheses. The entire cohort will be followed up every 6 months to determine the incidence of CKD and to identify risk factors for decline in kidney function. Qualitative studies will be performed to understand the community perceptions and expectations with respect to the interventions. Implications: CKD is an important public health challenge in low- and middle-income countries. This study will establish the prevalence and determine the incidence of CKD not associated with known risk factors in a reported high-burden region, and will provide insights to help design targeted health systems responses. The findings will contribute to the policy development to tackle CKD in the region and will permit international comparisons with other regions with similar high prevalence. Keywords: chronic kidney disease, CKD of uncertain etiology, risk factors

Published
2019
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14. Relationship between dialytic parameters and reviewer confirmed arrhythmias in hemodialysis patients in the monitoring in dialysis study

Author

James A. Tumlin, Prabir Roy-Chaudhury, Bruce A. Koplan, Alexandru I. Costea, Vijay Kher, Don Williamson, Saurabh Pokhariyal, David M. Charytan, and on behalf of the MiD investigators and Committees

Subjects
End stage renal disease, Hemodialysis, Cardiovascular disease, Arrhythmia, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Abstract Background Hemodialysis patients have high rates of sudden death, but relationships between serum electrolytes, the dialysis prescription, and intra-dialytic shifts in fluid and electrolyte with arrhythmia are uncertain. Methods We analyzed sixty-six hemodialysis patients who underwent loop recorder implantation with continuous electrocardiographic monitoring, weekly to bi-weekly testing of pre- and post-dialysis electrolytes, and detailed capture of dialysis prescription and flow sheet data for 6 months. The incidence rate ratio (IRR) of reviewer confirmed arrhythmias (RCA) during dialysis through 8 h after dialysis and associations with serum chemistries and dialytic parameters were assessed using adjusted, negative-binomial regression. Results Among 66 individuals with a mean age of 56 years, 12,480 events were detected in 64 (97%) patients. RCA nadired 12–24 h after dialysis and increased during the final 12 h of the inter-dialytic interval through the first 8 h after dialysis. Higher pre-dialysis serum magnesium concentration was associated with lower incidence rate ratio for arrythmia (IRR per 1 mg/dL increase 0.49, 95% CI; 0.25, 0.94), as was dialysate calcium concentration > 2.5 mEq/L vs. 2.5 mEq/L (IRR 0.52, 95% CI: 0.39, 0.70). Neither intradialytic serum potassium nor weight change were significantly associated with RCA rate. However, there was effect modification such that arrhythmia rate was maximal with concurrently high intradialytic volume and potassium removal (Pinteraction = 0.01). Conclusions Intra and post-dialytic arrhythmias are common in hemodialysis. Additional studies designed to further elucidate whether modification of the serum magnesium concentration, dialysate calcium concentration, and the extent of intradialytic potassium and fluid removal reduces the risk of per-dialytic arrhythmia are warranted. Trial registration Clinicaltrials.gov NCT01779856. Prospectively registered on January 22, 2013.

Published
2019
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15. Basiliximab induction in living donor kidney transplant with tacrolimus-based triple immunosuppression

Author

Shyam Bihari Bansal, Deepak Pathania, Sidharth Kumar Sethi, Pranaw Kumar Jha, Ashish Nandwani, Manish Jain, Amit Mahapatra, and Vijay Kher

Subjects
Basiliximab, induction, kidney transplant, living donor, tacrolimus, Surgery, RD1-811
Abstract

Introduction: Interleukin-2 receptor antagonists are recommended to reduce the risk of acute rejection (AR) in kidney transplant. This prospective study was undertaken to compare the incidence of AR with basiliximab induction as compared to no induction in first kidney recipients of living donors with tacrolimus (TAC)- and mycophenolate mofetil-based triple immunosuppression at 6 months. Methods: Two hundred and sixty patients were included in the study, 202 in the basiliximab group and 58 in the no induction group. Patients in the basiliximab group received two doses of 20 mg each on day 0 and day 4. The primary outcome was biopsy-proven AR at 6 months, and the secondary outcomes were incidence of infections and other adverse events along with graft and patient survival at the end of follow-up. All patients were followed up for a period of minimum 6 months. Results: There was no difference in baseline characteristics between the groups except higher human leukocyte antigen mismatch in the basiliximab group (3.80 ± 1.50 vs. 2.81 ± 1.53, P = 0.002). Forty-two (20.8%) patients in the basiliximab group developed AR at 6 months as compared to 10 (17.2%) in the no induction group (P = 0.55). There was no difference in adverse events between the groups. At a median follow-up of 1 year, graft survival (97% vs. 98.3%, P = 0.60) and patient survival (99% vs. 98.2%, P = 0.87) were also similar between the basiliximab and no induction groups, respectively. Conclusions: This study suggests that there is no advantage of using basiliximab induction in reducing AR in first kidney recipients of living donors in TAC-based triple immunosuppression.

Published
2019
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16. Impact of National Economy and Policies on End-Stage Kidney Care in South Asia and Southeast Asia

Author

Suceena Alexander, Sanjiv Jasuja, Maurizio Gallieni, Manisha Sahay, Devender S. Rana, Vivekanand Jha, Shalini Verma, Raja Ramachandran, Vinant Bhargava, Gaurav Sagar, Anupam Bahl, Mamun Mostafi, Jayakrishnan K Pisharam, Sydney C. W. Tang, Chakko Jacob, Atma Gunawan, Goh B. Leong, Khin T. Thwin, Rajendra K Agrawal, Kriengsak Vareesangthip, Roberto Tanchanco, Lina H. L. Choong, Chula Herath, Chih C. Lin, Nguyen T. Cuong, Ha P. Haian, Syed F Akhtar, Ali Alsahow, Mohan M. Rajapurkar, Vijay Kher, Hemant Mehta, Anil K. Bhalla, Umesh B. Khanna, Deepak S. Ray, Sonika Puri, Himanshu Jain, Aida Lydia, and Tushar Vachharajani

Subjects
Diseases of the genitourinary system. Urology, RC870-923
Abstract

Background. The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). Methods. Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. Results. Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and 10% in all the HE countries except Taiwan, 10%–20% in the majority of LE countries. Conclusion. Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.

Published
2021
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17. ABO-incompatible renal transplantation: The journey so far on a road less traveled

Author

Pranaw Kumar Jha, Ashish Nandwani, Ajay Kher, Shyam Bihari Bansal, Sidharth Sethi, Reetesh Sharma, Manish Jain, Dinesh Kumar Yadav, Dinesh Bansal, Rajan Duggal, Rajesh Ahlawat, and Vijay Kher

Subjects
ABO-incompatible transplant, developing world, India, renal transplantation, Surgery, RD1-811
Abstract

Introduction: ABO-incompatible (ABOi) renal transplant is the only option for patients who have neither blood group-compatible donors nor a suitable swap available. Published Indian experience of ABOi transplants has been far and few. Materials and Methods: This study was conducted across two different centers. All the consecutive ABOi renal transplants performed from November 2011 onward and who had completed at least 6 months of follow-up were included. Data were accessed retrospectively from the medical records. Results: There were fifty ABOi recipients who had completed at least 6 months of follow-up. Most common recipient blood group was group O. Median baseline antiblood group antibody titer (immunoglobulin G) was 256. Patient and death-censored graft survival were 94% and 88%, respectively, and biopsy-proven acute rejection was 22%. Acute antibody-mediated rejection was seen in 8% of the patients. Mean serum creatinine was 1.12 mg/dl at 1-month posttransplant and infection rate was 22%. Conclusion: The outcomes of ABOi transplant were acceptable and it should be promoted to bridge the demand and supply gap for renal transplant and expand the living donor pool.

Published
2018
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18. Prevention and Therapy of Acute Kidney Injury in the Developing World

Author

Vijay Kher, Nattachai Srisawat, Eisei Noiri, Mohammed Benghanem Gharbi, Manjunath S. Shetty, Li Yang, Arvind Bagga, Rajasekara Chakravarthi, and Ravindra Mehta

Subjects
acute kidney injury, confirmed, developing countries, management, prevention, resources, suspected, transient, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Timely recognition of patients at risk or with possible acute kidney injury (AKI) is essential for early intervention to minimize further damage and improve outcome. Initial management of patients with suspected and persistent AKI should include thorough clinical assessment of all patients with AKI to identify reversible factors, including fluid volume status, potential nephrotoxins, and an assessment of the underlying health of the kidney. Based on these assessments, early interventions to provide appropriate and adequate fluid resuscitation while avoiding fluid overload, removal of nephrotoxins, and adjustment of drug doses according to the level of kidney function derangement are important. The judicious use of diuretics for fluid overload and/or in cardiac decompensated patients and introduction of early enteral nutritional support need to be considered to improve outcomes in AKI. Although these basic principles are well recognized, their application in clinical practice in low resource settings is often limited due to lack of education, availability of resources, and lack of trained personnel, which limits access to care. We report the consensus recommendations of the 18th Acute Dialysis Quality Initiative meeting in Hyderabad, India, on strategies to evaluate patients with suspected AKI and initiate measures for prevention and management to improve outcomes, particularly in low resource settings. These recomendations provide a framework for caregivers, who are often primary care physicians, nurses, and other allied healthcare personnel, to manage patients with AKI in resource poor countries.

Published
2017
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19. A Familial Infantile Renal Failure

Author

Sidharth K. Sethi, Nikita Wadhwani, Pranaw Jha, Rajan Duggal, Virginia Vega-Warner, Rupesh Raina, Shyam B. Bansal, Vijay Kher, Matthew G. Sampson, and Edgar A. Otto

Subjects
Diseases of the genitourinary system. Urology, RC870-923
Published
2017
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21. A randomized controlled trial of cholecalciferol supplementation in patients on maintenance hemodialysis

Author

Beena Bansal, Shyam Bihari Bansal, Ambrish Mithal, Vijay Kher, R Marwaha, Padam Singh, and Nasir Irfan

Subjects
Cholecalciferol, chronic kidney disease, hemodialysis, India, vitamin D hemodialysis, Diseases of the endocrine glands. Clinical endocrinology, RC648-665, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

Background: Vitamin D deficiency is common in Indian patients with chronic kidney disease (CKD) on maintenance hemodialysis (MHD), but optimal dose of cholecalciferol is unclear. Materials and Methods: A total of 45 consenting patients were randomized to intervention and control groups. In the intervention group, patients (n = 35) with serum 25-hydroxy vitamin D (25(OH)D) < 30 ng/mL (n = 33), received oral cholecalciferol 60,000 units/week for 6 weeks. The serum levels of 25(OH)D, calcium, phosphorus, albumin, and parathyroid hormone (PTH) were measured at 0, 6, and 12 weeks. In the control group (n = 10), these were estimated at 0 and 6 weeks. Results: In the intervention group, 25/35 patients completed the supplementation at 6 weeks and 20/35 were available at 12 weeks. The mean baseline level of 25(OH)D was 9.59 ± 7.59 ng/mL, and after 6 weeks 19.51 ± 4.27 ng/mL, mean increase being 9.99 ± 6.83 ng/mL, which was highly significant (P < 0.0001). After discontinuing supplementation at 6 weeks, serum 25(OH)D level dropped significantly from 6 to 12 weeks [−2.84 ± 6.25 ng/mL (P = 0.04)]. However, it was still significantly higher at 12 weeks (16.08 ± 8.27 ng/mL) as compared with the baseline. PTH and calcium did not change significantly with supplementation. The change in serum 25(OH)D level from baseline to 6 weeks in the intervention group was inversely related to baseline 25(OH)D levels and patient′s weight. In the control group, change in 25(OH)D from baseline to 6 weeks was not significant. Conclusion: Supplementation with cholecalciferol 60,000 unit/week for 6 weeks was insufficient to achieve optimal levels of 25(OH)D in Indian patients with CKD on MHD.

Published
2014
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22. Protein energy wasting in chronic kidney disease: An update with focus on nutritional interventions to improve outcomes

Author

Yashpal P Jadeja and Vijay Kher

Subjects
Chronic kidney disease, nutritional intervention, protein energy malnutrition, protein energy wasting, Diseases of the endocrine glands. Clinical endocrinology, RC648-665, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD). PEW is one of the strongest predictors of mortality in patients with CKD. The International Society of Renal Nutrition and Metabolism (ISRNM) expert panel has defined PEW as a, "state of decreased body stores of protein and energy fuels (body protein and fat masses)". The ISRNM panel has also proposed diagnostic criteria of PEW with four categories. Cachexia is a severe form of PEW. The proposed causes of PEW are multi-factorial and include nutritional and non-nutritional mechanisms. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus and in children with CKD, in addition to dialysis patients. Features of ideal dietary supplement have also been discussed. Dietary interventions such as enteral feeding with high-protein meals or supplements might improve the nutritional status and outcomes in dialysis patients.

Published
2012
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23. Vitamin D deficiency in hemodialysis patients

Author

Beena Bansal, Shyam Bansal, Ambrish Mithal, Vijay Kher, and Raman Marwaha

Subjects
Chronic kidney disease, hemodialysis, vitamin D, Diseases of the endocrine glands. Clinical endocrinology, RC648-665, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

Background : Vitamin D [(25(OH)D] deficiency and insufficiency is common in patients with chronic kidney disease (CKD). 25(OH)D has been found to have beneficial effects on bone, cardiovascular and immune functions. There are little data about vitamin D levels in Indian patients on dialysis. This study was undertaken to determine the vitamin D status of Indian CKD patients on hemodialysis. Materials and Methods : We included 45 patients on maintenance hemodialysis coming to Medanta, Medicity, Gurgaon. 25(OH)D levels were measured with radioimmunoassay (Diasorin) method and parathyroid hormone (PTH) was measured using electrochemiluminiscence immunoassay (ECLIA). Results : The mean age of patients was 55 ± 13 years. 32/45 (71%) were males. 23/45 (51%) were diabetics. The median duration of hemodialysis was 5.5 months (range 1-74 months). 33/45 (74%) patients were on thrice weekly hemodialysis. The mean level of vitamin D was 10.14 ± 8.7 ng/ml. Majority of the patients [43/45 (95.5%)] were either vitamin D deficient or had insufficient levels. 40/45 (88.9%) were vitamin D deficient (levels

Published
2012
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24. Whole Exome Sequencing Reveals Novel PHEX Splice Site Mutations in Patients with Hypophosphatemic Rickets.

Author

Sara L Ma, Virginia Vega-Warner, Christopher Gillies, Matthew G Sampson, Vijay Kher, Sidharth K Sethi, and Edgar A Otto

Subjects
Medicine, Science
Abstract

Hypophosphatemic rickets (HR) is a heterogeneous genetic phosphate wasting disorder. The disease is most commonly caused by mutations in the PHEX gene located on the X-chromosome or by mutations in CLCN5, DMP1, ENPP1, FGF23, and SLC34A3. The aims of this study were to perform molecular diagnostics for four patients with HR of Indian origin (two independent families) and to describe their clinical features.We performed whole exome sequencing (WES) for the affected mother of two boys who also displayed the typical features of HR, including bone malformations and phosphate wasting. B-lymphoblast cell lines were established by EBV transformation and subsequent RT-PCR to investigate an uncommon splice site variant found by WES. An in silico analysis was done to obtain accurate nucleotide frequency occurrences of consensus splice positions other than the canonical sites of all human exons. Additionally, we applied direct Sanger sequencing for all exons and exon/intron boundaries of the PHEX gene for an affected girl from an independent second Indian family.WES revealed a novel PHEX splice acceptor mutation in intron 9 (c.1080-3C>A) in a family with 3 affected individuals with HR. The effect on splicing of this mutation was further investigated by RT-PCR using RNA obtained from a patient's EBV-transformed lymphoblast cell line. RT-PCR revealed an aberrant splice transcript skipping exons 10-14 which was not observed in control samples, confirming the diagnosis of X-linked dominant hypophosphatemia (XLH). The in silico analysis of all human splice sites adjacent to all 327,293 exons across 81,814 transcripts among 20,345 human genes revealed that cytosine is, with 64.3%, the most frequent nucleobase at the minus 3 splice acceptor position, followed by thymidine with 28.7%, adenine with 6.3%, and guanine with 0.8%. We generated frequency tables and pictograms for the extended donor and acceptor splice consensus regions by analyzing all human exons. Direct Sanger sequencing of all PHEX exons in a sporadic case with HR from the Indian subcontinent revealed an additional novel PHEX mutation (c.1211_1215delACAAAinsTTTACAT, p.Asp404Valfs*5, de novo) located in exon 11.Mutation analyses revealed two novel mutations and helped to confirm the clinical diagnoses of XLH in two families from India. WES helped to analyze all genes implicated in the underlying disease complex. Mutations at splice positions other than the canonical key sites need further functional investigation to support the assertion of pathogenicity.

Published
2015
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25. The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement

Author

H K Chopra, G S Wander, C K Ponde, Navin C Nanda, Dinesh Khullar, K Venugopal, Saumitra Ray, Tiny Nair, D S Rana, Vijay Kher, J P S Sawhney, R R Kasliwa, A Jabir, Rabin Chakraborty, Praveen Chandra, Sandeep Bansal, Viveka Kumar, A K Pancholia, Aditya Kapoor, Sunil Prakash, Anil Saxena, Vishal Rastogi, Vinod Sharma, Y K Arora, Arup Dasbiswas, Mohan Bhargava, Aparna Jaswal, K Bhargava, Mona Bhatia, A K Omar, N N Khanna, Rajiv Passey, Dilip Bhalla, I B Vijayalakshmi, A K Bhalla, Asha Moorthy, H S Isser, S S Mishra, S N Routray, Vivek Tandon, Ajay Sinha, Manish Bansal, Praveen Jain, Ramesh Hotchandani, Dharmendra Jain, V K Katyal, Sanjiv Gulati, Rohit Tandon, Shalini Jaggi, Blessy Sehgal, Vitull Gupta, Rahul Mehrotra, N C Krishnamani, S N Pathak, M S Yadav, Rajeev Chawla, Jyotirmoy Pal, Nandini Chatterjee, Shambo S Samajdar, and N R Shastry

Subjects
General Medicine
Abstract

Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril–Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril–Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril–Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril–Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40–50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk

Published
2023

26. Association of Bradycardia and Asystole Episodes with Dialytic Parameters: An Analysis of the Monitoring in Dialysis (MiD) Study

Author

Qandeel H. Soomro, Nisha Bansal, Wolfgang C. Winkelmayer, Bruce A. Koplan, Alexandru I. Costea, Prabir Roy-Chaudhury, James A. Tumlin, Vijay Kher, Don E. Williamson, Saurabh Pokhariyal, Candace K. McClure, and David M. Charytan

Subjects
Renal Dialysis, Dialysis Solutions, Bradycardia, Humans, Kidney Failure, Chronic, General Medicine, Heart Arrest, Original Investigation
Abstract

BACKGROUND: Bradycardia and asystole events are common among patients treated with maintenance hemodialysis. However, triggers of these events in patients on maintenance hemodialysis (HD), particularly during the long interdialytic period when these events cluster, are uncertain. METHODS: The Monitoring in Dialysis Study (MiD) enrolled 66 patients on maintenance HD who were implanted with loop recorders and followed for 6 months. We analyzed associations of predialysis laboratory values with clinically significant bradyarrhythmia or asystole (CSBA) during the 12 hours before an HD session. Associations with CSBA were analyzed with mixed-effect models. Adjusted negative binomial mixed-effect regression was used to estimate incidence rate ratios (IRR) for CSBA. We additionally evaluated associations of CSBA at any time during follow-up with time-averaged dialytic and laboratory parameters and associations of peridialytic parameters with occurrence of CSBA from the start of one HD session to the beginning of the next. RESULTS: There were 551 CSBA that occurred in the last 12 hours of the interdialytic interval preceding 100 HD sessions in 12% of patients and 1475 CSBA events in 23% of patients overall. We did not identify significant associations between dialytic parameters or serum electrolytes and CSBA in the last 12 hours of the interdialytic interval in adjusted analyses. Median time-averaged ultrafiltration rate was significantly higher in individuals without CSBA (9.8 versus 8, P=0.04). Use of dialysate sodium concentrations ≤135 (versus 140) mEq/L was associated with a reduced risk of CSBA from the start of one session to the beginning of next. CONCLUSIONS: Although a few factors had modest associations with CSBA in some analyses, we did not identify any robust associations of modifiable parameters with CSBA in the MiD Study. Further investigation is needed to understand the high rates of arrhythmia in the hemodialysis population.

Published
2022

27. SGLT2 Inhibitors in the Management of Chronic Kidney Disease: An Expert Consensus

Author

Vivekanand Jha, Alan Almeida, Arpita R Choudhury, Arup R Dutta, Dinesh Khullar, Gokulnath ., Urmila Anandh, Umesh Khanna, and Vijay Kher

Subjects
General Medicine
Abstract

Despite the availability of multiple therapies for chronic kidney disease (CKD), there still exists an unmet need for better options to slow down disease progression and prevent complications. The Dapagliflozin and Prevention of Adverse Outcomes in CKD (DAPA-CKD) trial, which demonstrated the renoprotective effects of the sodium-glucose cotransporter-2 inhibitor (SGLT2i) dapagliflozin, independent of diabetes, with improved survival, even in patients with CKD with estimated glomerular filtration rate (eGFR) as low as 25 mL/min/1.73 m2 , has highlighted the potential beneficial role of SGLT2i in patients with CKD. These benefits were also achieved in patients who were already receiving optimal therapies for slowing the progression of CKD. The potential candidature of SGLT2i for CKD therapy is now being widely discussed in the nephrology community. Therefore, a consensus meeting was held in September 2020 with a group of expert nephrologists from India, to discuss the need to improve CKD management and assess the position of SGLT2i, based on compelling evidence from recent studies. This document summarizes the expert opinions and views on the position of SGLT2i in CKD management and aims to enhance the current understanding of the applicability of SGLT2i in patients with CKD. This will aid nephrologists and physicians across the country in decision-making on the management of patients with CKD using SGLT2i. Keywords: Chronic kidney disease, Dapagliflozin, Estimated glomerular filtration rate, SGLT2i inhibitors, Type 2 diabetes mellitus.

Published
2022

28. Renal Outcomes in Neonates and Infants with Transposition Physiology Undergoing Arterial Switch Procedure

Author

Rajesh Sharma, Anil Bhan, Arushi Nautiyal, Aliza Mittal, Romel Akole, Neha Malhotra, Firdoos Ahmad Mir, Pankaj Bajpai, Amit Misri, Swarnika Srivastava, Ved Prakash, Abhishek Tibrewal, Pranaw Kumar Jha, Shyam Bihari Bansal, Vijay Kher, Rupesh Raina, and Sidharth Kumar Sethi

Subjects
Arterial Switch Operation, Norepinephrine, Dopamine, Transposition of Great Vessels, Pediatrics, Perinatology and Child Health, Infant, Newborn, Infant, Humans, Prospective Studies, Acute Kidney Injury, Child, Cardiology and Cardiovascular Medicine
Abstract

Acute kidney injury (AKI) in children with Transposition of Great arteries (TGA) undergoing Arterial Switch operation (ASO) is an important complication in the post-operative period associated with worse outcomes. AKI in children post open cardiac surgery has been well studied, with lesser data in literature pertaining to TGA and its sub-types specifically. This was a prospective, observational study enrolling infants with TGA undergoing ASO at a single center over a span of a decade from January 2010 to December 2020. The infants were followed during the duration of ICU and hospital stay, with documentation of baseline and intraoperative parameters as well as post-operative course. Out of 145 infants enrolled in the study, 83.1% developed AKI with majority (83.9%) having stage 1 AKI. Higher odds of AKI were seen in infants requiring Norepinephrine [odds ratio - 16.76 (95% CI 2.19-128.2), p 0.001] and those who developed gram-negative infections [2.81 (1.04-7.56), p - 0.036]. Infants with AKI had significantly higher vasoactive-inotropic support at day 1 than those without AKI [16 (12.5-21.50 vs 13 (10.25-15.75), p - 0.014]. Seventeen infants in the AKI group (14%) died as opposed to none in the non-AKI group (p = 0.076). Median hours of ventilator support required were significantly higher in those with AKI than those who did not develop AKI (48 vs 45.5 p = 0.015). The infants with ASO + ASD + PDA (53% of neonates who died) were younger, had less weight at admission, more gram-negative sepsis and need for dopamine, as compared to ASO + VSD + ASD (23.5% of mortality) and ASO + ASD + VSD + aortic arch repair (23.5% of mortality). AKI in infants with TGA undergoing ASO is common and associated with poorer outcomes. In this subpopulation, AKI development is associated most commonly with hemodynamic instability and infections. This is the first study, looking at outcomes of TGA depending on the sub-types of ASO surgeries done in the infants [ASO with ASD + PDA or ASD + VSD or ASD + VSD + Arch Repair].

Published
2022

29. Chronic Kidney Disease of Unknown Etiology in India: What Do We Know and Where We Need to Go

Author

Sreejith Parameswaran, Vidhya Venugopal, Manisha Sahay, Oommen John, Vivek Kumar, Balaji Gummudi, Nicolas Osborne, Om P. Kalra, Vinay Rathore, Prabhdeep Kaur, Anubhuti Jha, Sanghamitra Pati, Ravi Shankar Machiraju, Vijay Kher, Jarnail Singh Thakur, Subrata Kumar Palo, Narayan Prasad, Mohan Rajapurkar, Ravi Raju Tatapudi, Vivekanand Jha, and Natarajan Gopalakrishnan

Subjects
medicine.medical_specialty, education.field_of_study, Referral, business.industry, Public health, Population, Meeting Report, heat stress nephropathy, medicine.disease, climate change, Nephrology, Family medicine, medicine, Etiology, Sri lanka, education, business, Socioeconomic status, chronic kidney disease, Disease burden, chronic kidney disease of uncertain etiology, Kidney disease
Abstract

Chronic kidney disease (CKD) not associated with known risk factors has been reported from parts of India and is presumed to be similar to CKD of unknown etiology (CKDu) that has been described from Central America. The reports from India have been fragmented without clear description of the disease phenotype or its determinants. This paper summarizes the current state of knowledge around CKDu in India based on a review of literature, multi-stakeholder consultation, and a survey of Indian nephrologists. We also contacted individual research groups to solicit data. Our findings suggest that that CKDu is reported from most regions in India; however, it is interpreted differently from the phenotype described from Central America and Sri Lanka. The differences include lack of a clear demographic or occupation group, older age of affected participants, and presence of mild hypertension and low-grade proteinuria. Well-designed prospective field studies with appropriate diagnostic workup are needed to establish the disease burden and identify etiologies, along with socioeconomic and health consequences, the intersection with the environment, and the public health response. Community-based research should phenotype the entire CKD population rather than be restricted to cases with presumed CKDu based on predefined criteria. Guidelines are needed for clinical evaluation, referral, management, and harmonization of clinical documentation and health records. More data are needed to support the existence of a unique CKDu phenotype in India.

Published
2021

30. Long-Term Renal Outcomes in Children With Acute Kidney Injury Post Cardiac Surgery

Author

Kritika Soni, Pranaw Kumar Jha, Anil Bhan, Rupesh Raina, Vijay Kher, Aditi Gupta, Rajesh Sharma, Shyam Bihari Bansal, Rohan Dhir, Sidharth Kumar Sethi, Abhishek Tibrewal, and Romel Akole

Subjects
medicine.medical_specialty, pediatrics, Urinary system, 030232 urology & nephrology, Urology, Renal function, 030204 cardiovascular system & hematology, urologic and male genital diseases, law.invention, 03 medical and health sciences, 0302 clinical medicine, Clinical Research, law, Cardiopulmonary bypass, medicine, Univariate analysis, Proteinuria, urogenital system, business.industry, Acute kidney injury, biomarkers, medicine.disease, female genital diseases and pregnancy complications, Cardiac surgery, acute kidney injury, Nephrology, Biomarker (medicine), medicine.symptom, cardiopulmonary bypass, business, cardiac surgery, chronic kidney disease
Abstract

Introduction The long-term renal outcomes of survivors of pediatric acute kidney injury (AKI) are varied within the current literature, and we aim to establish long-term renal outcomes for pediatric patients after cardiac surgery. We studied long-term renal outcomes and markers of kidney injury in pediatric patients after congenital cardiac surgery. Methods In a prospective case-control observational study (the Renal Outcomes in Children with acute Kidney injury post cardiac Surgery [ROCKS] trial) we reviewed all children who underwent cardiac surgery on cardiopulmonary bypass (December 2010–2017). Results During the study period, 2035 patients underwent cardiac surgery, of whom 9.8% developed AKI postoperatively. Forty-four patients who had postoperative AKI had a long-term follow-up, met our inclusion criteria, and were compared with 49 control subjects. We conducted a univariate analysis of reported parameters. At a median follow-up of 41 months, the cases had significantly higher urine levels of neutrophil gelatinase–associated lipocalin (NGAL), interleukin-18 (IL-18), and kidney injury molecule-1 (KIM-1). The biomarkers remained higher after adjusting for the urine creatinine, and the ratio of urine KIM-1/urine creatinine was significantly higher among cases. None of the patients had proteinuria or hypertension on follow-up. The presence of AKI, AKI stage, and younger age were not associated with the occurrence of low glomerular filtration rate (GFR) at follow-up. Conclusions Urinary biomarker abnormalities persist years after a congenital cardiac surgery in children, who may have a low GFR on follow-up. The presence of AKI, AKI stage, and younger age at surgery are not associated with the occurrence of low GFR at follow-up. Children with a higher surgical complexity score have lower GFR on follow-up., Graphical abstract

Published
2021

31. A Multicenter Cohort Study From India of 75 Kidney Transplants in Recipients Recovered After COVID-19

Author

Deepak Shankar Ray, Dinesh Khullar, Umesh T Varyani, Vishwanath Siddini, Dinesh Kumar Yadav, Rushi Deshpande, Anil M. S. Kumar, M.M. Bahadur, Vijay Kher, Pranaw Kumar Jha, Urmila Anandh, S. Guleria, Abi Abraham M, Kamal Kaswan, Manoj R. Gumber, Suraj Godara, Ashay Shingare, Shailesh Kakde, Hari Shankar Meshram, Anil Kumar Bhalla, Vivek B Kute, Himanshu V Patel, Sanjeev Gulati, Sonal Dalal, Umapati Hegde, Manish Jain, Ashish Sharma, Sharmila Thukral, Vivek M. Pathak, Rabi Ranjan Sow Mondal, Deepesh Benjamin Kenwar, and Raj Kumar Sharma

Subjects
Adult, Male, medicine.medical_specialty, medicine.medical_treatment, India, 030230 surgery, Asymptomatic, Donor Selection, 03 medical and health sciences, 0302 clinical medicine, Interquartile range, Internal medicine, Humans, Medicine, Survivors, Prospective cohort study, Kidney transplantation, Aged, Retrospective Studies, Transplantation, business.industry, Patient Selection, COVID-19, Retrospective cohort study, Immunosuppression, Middle Aged, medicine.disease, Kidney Transplantation, Treatment Outcome, Kidney Failure, Chronic, Female, 030211 gastroenterology & hepatology, medicine.symptom, business, Follow-Up Studies, Cohort study
Abstract

Background There is limited current knowledge on feasibility and safety of kidney transplantation in COVID-19 survivors. Methods We present a retrospective cohort study of 75 kidney transplants in patients who recovered from polymerase chain reaction (PCR) confirmed COVID-19 performed across 22 transplant centers in India from July 3, 2020 to January 31, 2021. We detail demographics, clinical manifestations, immunosuppression regimen, laboratory findings, treatment and outcomes. Patients with a previous diagnosis of COVID-19 were accepted after documenting 2 negative SARS-CoV-2 PCR tests, normal chest imaging with complete resolution of symptom for at least 28 days and significant social distancing for 14 days prior to surgery. Results Clinical severity in patients ranged from asymptomatic (n=17, 22.7%), mild(n=36,48%), moderate(n=15,20%) and severe(n=7,9.3%) disease. Median duration between PCR positive to transplant was 60 days (overall) and, increased significantly from asymptomatic, mild, moderate and severe disease (49,57,83,94 days, P-value 0.019) respectively. All recipients and donors were asymptomatic with normal creatinine after surgery at a median (interquartile range) follow up of 81 (56-117) days without any complications relating to surgery or COVID-19. Patient and graft survival was 100%, and acute rejection was reported in 6.6%. Conclusions Prospective kidney transplant recipients post-COVID-19 can be considered for transplantation after comprehensive donor and recipient screening before surgery using a combination of clinical, radiologic, and laboratory criteria, careful pre-transplant evaluation, and individualized risk-benefit analysis. Further large-scale prospective studies with longer follow-up will better clarify our initial findings. Till date, this remains the first largest study of kidney transplantation in COVID-19 survivors.Supplemental Visual Abstract; http://links.lww.com/TP/C180.

Published
2021

32. Electrolyte Changes in Contemporary Hemodialysis: A Secondary Analysis of the Monitoring in Dialysis Study

Author

MiD Investigators, Don Williamson, David M. Charytan, S Pokhariyal, Prabir Roy-Chaudhury, Candace K. McClure, Vijay Kher, Simon Correa, Committees, Katherine Mikovna Scovner, James A. Tumlin, Finnian R. Mc Causland, Alexandru Costea, and Bruce A. Koplan

Subjects
medicine.medical_specialty, medicine.medical_treatment, Urology, Electrolyte, Article, Electrolytes, chemistry.chemical_compound, Renal Dialysis, Dialysis Solutions, medicine, Humans, Prospective Studies, Dialysis, Creatinine, business.industry, Albumin, General Medicine, Nomogram, medicine.disease, Hypokalemia, Bicarbonates, chemistry, Hemodialysis, medicine.symptom, business, Hypophosphatemia
Abstract

BACKGROUND: There is a paucity of contemporary data examining electrolyte changes during and immediately after hemodialysis (HD), and their relationship with dialysate prescriptions. The present study examines these relationships. METHODS: We analyzed patient- (n=66) and HD session-level pre- and post-dialysis laboratory data (n=1,713) over a six-month period from the Monitoring in Dialysis Study. We fit mixed effects regression models to analyze electrolyte, blood urea nitrogen, creatinine, and albumin levels immediately post-HD, accounting for pre-HD and dialysate prescriptions. In a subset of US patients (n=40), 15-minute post-HD and 30-minute post-HD values were available at one session. Predictive models were fit to estimate electrolyte levels immediately post-HD, accounting for pre-HD concentrations and dialysate prescriptions. RESULTS: Serum bicarbonate, calcium, and albumin increased (mean increase 4.9±0.3 mEq/L, 0.7±0.1 mEq/L, and 0.4±0.03 g/dL, respectively), whereas potassium, magnesium, and phosphorus decreased immediately post-HD (mean −1.2±0.1 mEq/L, −0.3±0.03 mEq/L, and −3.0±0.2 mg/dL, respectively). Hypokalemia and hypophosphatemia were present in 40% of and 67% of immediate post-HD samples, respectively. Dynamic changes were observed in electrolyte concentrations at 15- and 30-minutes post-HD, compared to immediately post-HD. CONCLUSION: We describe the magnitude of post-dialytic changes in serum electrolytes with contemporary HD, reporting a high incidence of electrolyte abnormalities post-HD, and present predictive nomograms relating electrolyte changes immediately post-HD to dialysate prescriptions. Our results may be useful for clinical care and provide insights for future research on dialysate prescriptions.

Published
2021

33. Robotic Kidney Transplantation with Regional Hypothermia versus Open Kidney Transplantation for Patients with End Stage Renal Disease: An Ideal Stage 2B Study

Author

Hallie Wurst, Prasun Ghosh, Phil Olson, Vijay Kher, Mahendra Bhandari, Akshay Sood, Rajesh Ahlawat, Guillaume Farah, Jacob Keeley, Mani Menon, Wooju Jeong, and Firas Abdollah

Subjects
Adult, Male, medicine.medical_specialty, Urology, 030232 urology & nephrology, End stage renal disease, 03 medical and health sciences, 0302 clinical medicine, Robotic Surgical Procedures, Hypothermia, Induced, medicine, Humans, Prospective Studies, Stage (cooking), Prospective cohort study, Kidney transplantation, Kidney, Ideal (set theory), business.industry, Middle Aged, Hypothermia, medicine.disease, Kidney Transplantation, Surgery, Treatment Outcome, medicine.anatomical_structure, Kidney Failure, Chronic, Female, medicine.symptom, business
Abstract

We report on comparative effectiveness of minimally invasive versus traditional open kidney transplantation.We undertook a prospective cohort study of 654 patients who underwent open or robotic kidney transplantation at a single tertiary care hospital between January 2013 and December 2015. Primary outcome was delayed graft function, defined as the need for dialysis within 1 week of surgery. Secondary outcomes included postoperative complications, pain, graft rejection, and graft and patient survival. Nonparsimonious propensity score and Ding-VanderWeele analytical methods were used to account for confounding bias.Within the 1:3 matched cohort (robotic 126, open 378; well matched with standardized mean difference ∼10%), the robotic approach was associated with lower rates of wound infections (0% vs 4%, p=0.023) and symptomatic lymphoceles (0% vs 7% at 36 months, p=0.003), as well as reduced postoperative pain, requirement for narcotic analgesia and blood loss. There were no differences between the 2 groups, robotic versus open, with respect to graft function (delayed graft function 0% vs 2.4%, p=0.081), hospital stay (median 8 days for both, p=0.647), graft rejection (16.2% vs 18.6% at 36 months, p=0.643), and graft (95.2% vs 96.3% at 36 months, p=0.266) and overall survival (94.5% vs 98.1% at 36 months, p=0.307). Ding-VanderWeele analysis suggested minimal influence of unknown confounders on study findings.Robotic kidney transplantation with regional hypothermia was associated with a lower rate of postoperative complications and improved patient comfort in comparison to open kidney transplantation. Graft function, and graft and overall survival were comparable between the 2 techniques.

Published
2021

34. Grafalon® vs. Thymoglobulin® as an induction agent in renal transplantation – A retrospective study

Author

Dinesh Bansal, Amit Mahapatra, Pranaw Kumar Jha, Dinesh Kumar Yadav, Puneet Sodhi, Sidharth Kumar Sethi, Vijay Kher, Ashish Nandwani, Shyam Bihari Bansal, Manish Jain, Ashwini Gadde, Ajay Kher, and Abhyudaysingh Rana

Subjects
thymoglobulin, medicine.medical_specialty, Thymoglobulin, business.industry, medicine.medical_treatment, Urology, india, rabbit, Renal function, kidney transplantation, Retrospective cohort study, Immunosuppression, medicine.disease, Diseases of the genitourinary system. Urology, Transplantation, Nephrology, Median follow-up, Prednisolone, medicine, Original Article, RC870-923, business, antilymphocyte serum, Kidney transplantation, medicine.drug
Abstract

Introduction: Antihuman thymocyte immunoglobulin, used as an induction agent in renal transplantation, is of two types – thymoglobulin and grafalon (formerly ATG-Fresenius). In this study, we compared outcomes with these two agents. Methods: This was a single-center retrospective study of patients transplanted from January 2017 to October 2019, who received either grafalon or thymoglobulin induction. Grafalon or thymoglobulin was given at 6 and 3 mg/kg, respectively, followed by standard triple immunosuppression of tacrolimus, MMF, and prednisolone. Results: Median follow up was 22 (3–36) months. Thymoglobulin was given to 255 patients, whereas 78 patients received grafalon. Baseline demographics were similar between the two groups although significantly more patients in the grafalon group received ABO incompatible transplant (15% vs. 4.3%; P = 0.002). Patient survival was similar between the two groups (99% in grafalon vs. 98.8% in thymoglobulin; P = 1.0). Death censored graft survival was also similar (99% in grafalon vs. 100% in thymoglobulin; P = 0.23). Biopsy proven acute rejection (BPAR) was significantly higher in the grafalon group (12.8% vs. 5.1%, P = 0.04). The significance persisted after multivariable regression analysis (P = 0.02). Other outcomes such as infection rate and estimated glomerular filtration rate on last follow up were comparable between the two groups. Conclusions: Grafalon (6 mg/kg dose) when used as an induction agent was associated with significantly higher rate of BPARs as compared to thymoglobulin (3 mg/kg dose) although with comparable short-term patient and death censored graft survival, graft function, and infection rates.

Published
2021

35. Evaluation of screening tests for pre-transplant compatibility testing in live-related kidney transplants: Single-center report from India - A prospective observational study

Author

Simmi Mehra, Vijay Kher, Shyam Bihari Bansal, Geet Aggarwal, Aseem K Tiwari, Rajni Chauhan, and Chhavi Rajvanshi

Subjects
Transplantation, medicine.medical_specialty, pre-transplant, Compatibility testing, biology, RD1-811, business.industry, Gold standard (test), Human leukocyte antigen, compatibility, medicine.disease, Single Center, Antigen, live-related, Internal medicine, renal transplant, medicine, biology.protein, Surgery, Antibody, business, single-antigen bead, Kidney transplantation
Abstract

Introduction: Pre-transplant compatibility testing involves the use of different methodologies (cell-based and solid phase based) for the determination of anti-human-leukocyte antigen (HLA) antibodies. Implementation of these donor-recipient methods in the screening of patients awaiting transplantation increased their chance of successful graft and patient outcomes. Materials and Methods: A total of 1054 patients visiting tertiary care hospitals for pretransplant compatibility testing were screened with cell-based tests; complement-dependent cytotoxicity crossmatch (CDC-XM) and flow cytometric crossmatch (FC-XM). The patients positive for either or both screening tests were suspected to have anti-HLA antibodies. Luminex single-antigen bead (SAB) tests were performed in such patients to determine and identify antibody specificity and establish donor-specific antibody (DSA). Results: The study showed a significantly higher sensitivity of the FCXM (94.6%) method when compared with CDC-XM (35.7%), considering the SAB assay as the gold standard technique. The specificity of CDC-XM (100%) was slightly higher than the FC-XM (76.3%). Combination of FC-XM with CDC-XM (17 cases) was 100% sensitive and specific to identify DSA (s). The graft-survival was 94.77% using the proposed algorithm. Conclusions: The combination of CDC-XM and FC-XM, along with SAB assay, could be used as a screening algorithm as it is a useful technique in identifying the specificities of alloantibodies, assessment of DSAs. Hence, the presented algorithm can become a new standard for the identification of potential recipients awaiting kidney transplantation in India.

Published
2021

36. A Systematic Study of the Prevalence and Risk Factors of CKD in Uddanam, India

Author

Geetha Prasadini, Chandra M. Pandey, Balaji Gummidi, Jayaprakash Muliyil, Arpita Ghosh, Gopesh K. Modi, Lakshmy Ramakrishnan, Vijay Kher, Jarnail Singh Thakur, Tripti Khanna, Jawahar Reddy, Oommen John, R S Dhaliwal, Meena Sehgal, Aruna Kumari, Vivekanand Jha, Vishnubhotla Sivakumar, Janardhan C. Reddy, and Om P. Kalra

Subjects
medicine.medical_specialty, hypertension, Population, 030232 urology & nephrology, Renal function, 030204 cardiovascular system & hematology, urologic and male genital diseases, 03 medical and health sciences, symbols.namesake, chemistry.chemical_compound, Uddanam, 0302 clinical medicine, Clinical Research, Internal medicine, medicine, risk factors, Poisson regression, Family history, education, Creatinine, education.field_of_study, Proteinuria, High prevalence, business.industry, CKD of unknown etiology, medicine.disease, chemistry, Nephrology, symbols, proteinuria, medicine.symptom, business, chronic kidney disease, Kidney disease
Abstract

Introduction Despite reports of a high prevalence of chronic kidney disease (CKD) from the coastal Uddanam region of Andhra Pradesh, India, there are no accurate data on the distribution of kidney function abnormalities and CKD risk factors in this region. Methods A total of 2419 participants were recruited through multistage cluster random sampling from 67 villages. Serum creatinine and urine protein creatinine ratio were measured using validated methodologies. All abnormal estimated glomerular filtration rate (eGFR) and urine protein creatinine ratio values were reconfirmed after 3 months. A range of sociodemographic factors were evaluated for their association with CKD using Poisson regression. Results Of 2402 eligible subjects (mean ± SD age, 45.67 ± 13.29 years; 51% female), 506 (21.07%) had CKD (mean ± SD age, 51.79 ± 13.12 years; 41.3% female). A total of 246 (10.24%) had eGFR 0.15 g/g). The poststratified estimates, adjusted for age and sex distribution of the region for CKD prevalence, are 18.7% (range, 16.4%–21.0%) overall and 21.3% (range, 18.2%–24.4% ) and 16.2% (range, 13.7%–18.8%) in men and women, respectively. Older age, male sex, tobacco use, hypertension, and family history of CKD were independently associated with CKD. Compared with those with higher eGFR, those with eGFR 0.15, except a lower frequency of males in the former. Conclusion We confirmed the high prevalence of CKD in the adult population of Uddanam. The cause was not apparent in a majority. Subjects with a low eGFR with or without elevated proteinuria were phenotypically distinct from those with proteinuria and preserved eGFR. Our data suggest the need to apply a population-based approach to screening and prevention and studies to understand the causes of CKD in this region., Graphical abstract

Published
2020

37. A rare complication of pauci-immune crescentic glomerulonephritis in a child: Answers

Author

Abhyuday Rana, Sidharth Kumar Sethi, Marie-Agnès Dragon-Durey, Vijay Kher, Alka Rana, Shyam Bihari Bansal, Kritika Soni, Rupesh Raina, and Dinesh Kumar Yadav

Subjects
Nephrology, medicine.medical_specialty, Thrombotic microangiopathy, Crescentic glomerulonephritis, business.industry, Anemia, medicine.disease, Dermatology, Pauci-immune, Internal medicine, Pediatrics, Perinatology and Child Health, medicine, Alternative complement pathway, medicine.symptom, business, Complication
Published
2020

38. Prevention and Therapy of AKI in Asia: A Big Challenge

Author

Vijay Kher and Ajay Kher

Subjects
0301 basic medicine, medicine.medical_specialty, Asia, Population, 030232 urology & nephrology, Context (language use), urologic and male genital diseases, 03 medical and health sciences, 0302 clinical medicine, Health care, Humans, Medicine, Intensive care medicine, education, Socioeconomic status, education.field_of_study, urogenital system, business.industry, Acute kidney injury, Acute Kidney Injury, medicine.disease, female genital diseases and pregnancy complications, 030104 developmental biology, Nephrology, business, Developed country
Abstract

Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.

Published
2020

39. Intradialytic Hypotension and Cardiac Arrhythmias in Patients Undergoing Maintenance Hemodialysis

Author

Finnian R. Mc Causland, Jim A. Tumlin, Vijay Kher, S Pokhariyal, Don Williamson, Prabir Roy-Chaudhury, Bruce A. Koplan, Alexandru Costea, David M. Charytan, and Committees

Subjects
Male, Bradycardia, medicine.medical_specialty, Epidemiology, medicine.medical_treatment, India, Critical Care and Intensive Care Medicine, Ventricular tachycardia, Rate ratio, Sudden death, Renal Dialysis, Internal medicine, medicine, Humans, Prospective Studies, Renal Insufficiency, Dialysis, Aged, Transplantation, business.industry, Incidence, Incidence (epidemiology), Arrhythmias, Cardiac, Original Articles, Middle Aged, medicine.disease, United States, Confidence interval, Nephrology, Cardiology, Female, Hemodialysis, Hypotension, medicine.symptom, business
Abstract

BACKGROUND AND OBJECTIVES: Patients receiving maintenance hemodialysis (HD) have a high incidence of cardiac events, including arrhythmia and sudden death. Intradialytic hypotension (IDH) is a common complication of HD and is associated with development of reduced myocardial perfusion, a potential risk factor for arrhythmia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We analyzed data from the Monitoring in Dialysis study, which used implantable loop recorders to detect and continuously monitor electrocardiographic data from patients on maintenance HD (n=66 from the United States and India) over a 6-month period (n=4720 sessions). Negative binomial mixed effects regression was used to test the association of IDH(20) (decline in systolic BP >20 mm Hg from predialysis systolic BP) and IDH(0–20) (decline in systolic BP 0–20 mm Hg from predialysis systolic BP) with clinically significant arrhythmia (bradycardia≤40 bpm for ≥6 seconds, asystole≥3 seconds, ventricular tachycardia ≥130 bpm for ≥30 seconds, or patient-marked events) during HD. RESULTS: The median age of participants was 58 (25th–75th percentile, 49–66) years; 70% were male; and 65% were from the United States. IDH occurred in 2251 (48%) of the 4720 HD sessions analyzed, whereas IDH(0–20) occurred during 1773 sessions (38%). The number of sessions complicated by least one intradialytic clinically significant arrhythmia was 27 (1.2%) where IDH(20) occurred and 15 (0.8%) where IDH(0–20) occurred. Participants who experienced IDH(20) (versus not) had a nine-fold greater rate of developing an intradialytic clinically significant arrhythmia (incidence rate ratio, 9.4; 95% confidence interval, 3.0 to 29.4), whereas IDH(0–20) was associated with a seven-fold higher rate (incidence rate ratio, 7.2; 95% confidence interval, 2.1 to 25.4). CONCLUSIONS: IDH is common in patients on maintenance HD and is associated with a greater risk of developing intradialytic clinically significant arrhythmia.

Published
2020

40. Challenges of Conducting Clinical Trials during the SARS-CoV-2 Pandemic: The ASCEND Global Program Experience

Author

Kirsten L. Johansen, Anjali Acharya, Borut Cizman, Alexander R. Cobitz, Ricardo Correa-Rotter, Indranil Dasgupta, Vijay Kher, Renato D. Lopes, Leonardo Matsumoto, Amy M. Meadowcroft, Osvaldo Merege Vieira Neto, Marilu Okabe, Brian Rayner, Arnold Silva, Hilary Thomas, and Ajay K. Singh

Subjects
Clinical Trials as Topic, Data Collection, COVID-19, Humans, General Medicine, Brief Communication, R1, Pandemics
Abstract

The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented effect on health and health care. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has strained health care systems and caused disruption to non-COVID-19-related health care. Although the premature interruption or disruption of clinical trials is less well recognized, it has the potential to threaten the development of new non-COVID-19-related therapies (1⇓–3).\ud \ud Study disruptions need to be rapidly identified and addressed to preserve the integrity of ongoing studies and the design of new ones. Here, we describe the challenges that arose in three global phase 3 trials and the strategies undertaken to maintain and adapt the conduct of the studies safely during the COVID-19 pandemic.

Published
2022

41. Management Strategies and Outcomes in Renal Transplant Recipients Recovering from COVID-19: A Retrospective, Multicentre Study

Author

Vivek Kute, Deepak S. Ray, Feroz Aziz, Suraj M. Godara, Umapati Hegde, Anil Kumar BT, Anil K. Bhalla, Dinesh Kumar Yadav, Sarbpreet Singh, Vivek Pathak, Sonal Dalal, Madan M. Bahadur, Urmila Anandh, Abi abraham, Vishwanath Siddini, Sushree Sashmita Das, Sharmila Thukral, Arvind Krishnakumar, Ashish Sharma, Vijay Kher, Shyam B. Bansal, Ashay Shingare, Ranjit Narayanan, Himanshu Patel, Sanjeev Gulati, Shailesh Kakde, Dinesh Bansal, Sandeep Guleria, Dinesh Khullar, Manoj R. Gumber, Umesh Varyani, Swarnalatha G, Prakash Khetan, Rutul Dave, Vineet V. Mishra, Tullius G. Stefan, Sanshriti Chauhan, and Hari Shankar Meshram

Published
2022

42. Health status after invasive or conservative care in coronary and advanced kidney disease

Author

Spertus J. A., Jones P. G., Maron D. J., Mark D. B., O'Brien S. M., Fleg J. L., Reynolds H. R., Stone G. W., Sidhu M. S., Chaitman B. R., Chertow G. M., Hochman J. S., Bangalore S, ISCHEMIA-CKD Research Group: Abdallah M Abdallah, Abel E Moreyra, Abhay A Laddu, Abhishek Dubey, Abhishek Goyal, Abigail Knighton, Adedayo Adeboye, Agne Juceviciene, Agne Urboniene, Agnieszka Szramowska, Ahmed Abdel-Latif, Ahmed Ayoub, Ahmed Elghamaz, Ahmed Kamal, Ahmed Talaat, Ajay Sharma, Ajit Singh Narula, Akshay Bagai, Akvile Smigelskaite, Alain Raymond, Alain Rheault, Alaine Melanie Loehr, Albert Varga, Aldo P Maggioni, Alec Moorman, Alejandro Chevaile Ramos, Alejandro Gisbert, Aleksandra Fratczak, Aleksandras Laucevicius, Alexander M Chernyavskiy, Alexander Sergeevich Borisov, Alexandra Craft, Alexandra Hunter, Alexandre Ciappina Hueb, Alexandre Schaan de Quadros, Alice Manica Muller, Aline Peixoto Deiro, Allegra Stone, Almudena Castro, Amar Uxa, Amaryllis Van Craenenbroeck, Ambuj Roy, Amit Kakkar, Amy Flowers, Amy Iskandrian, Ana D Djordjevic-Dikic, Ana Gomes Almeida, Ana Rita Francisco, Ana S Mladenovic, Ana Santana, Anandaroop Lahiri, Anastasia M Kuzmina-Krutetskaya, Anastasia Vamvakidou, Andras Vertes, Andre Gabriel, Andrea Bartykowszki, Andrea Lorimer, Andrea Pascual, Andreia Coelho, Andreia Rocha, Andrés García-Rincón, Andrew Starovoytov, Andrzej Łabyk, Anelise Kawakami, Angela Hoye, Angelo Nobre, Anjali Acharya, Anjali Anand, Anjana Rishmawi, Ann Banfield, Ann Luyten, Anna Cichocka-Radwan, Anna Fojt, Anna Plachcinska, Anna Teresinska, Anne Marie Webb, Anne Heath, Anoop Mathew, Antonia Vega, Antonio Carvalho, Antonio Colombo, Antonio Fiarresga, Anu Tharini, Anupama Rao, Aquiles Valdespino-Estrada, Ariel Diaz, Arif Asif, Arnold H Seto, Arturo S Campos-Santaolalla, Asim N Cheema, Asker Ahmed, Atul Mathur, Audrey W Leong, Axel Åkerblom, Axelle Fuentes, Aynun Naher, Badhma Valaiyapathi, Balaji Srinivasan, Baljeet Kaur, Balram Bhargava, Bandula Guruge, Barbara Wicklund, Bartosz Czarniak, Bebek Singh, Begoña Igual, Bela Merkely, Benoy N Shah, Bernard de Bruyne, Beth Abramson, Beth Stefanchik, Bethany Harvey, Bharati Shivalkar, Bilal Malik, Binoy Mannekkattukudy Kurian, Bougrida Hammouche, Branko D Beleslin, Bruce Ferguson, Bruce McManus, Bruna Maria Ascoli, Bryn Smith, Byron J Allen, C Michael Gibson, C Noel Bairey Merz, Calin Pop, Carl-Éric Gagné, Carly Ohmart, Carol M Kartje, Caroline Alsweiler, Caroline Rodgers, Caroline Spindler, Carolyn J Gruber, Catherine Albert, Catherine Bone, Catherine Lemay, Cezary Kepka, Chandini Suvarna, Chantale Mercure, Charlene Wiyarand, Chetan Patel, Chiara Attanasio, Chi-Ming Chow, Ching Min Er, Ching-Ching Ong, Cholenahally Nanjappa Manjunath, Chris Buller, Christel Vassaliere, Christiaan Vrints, Christian Witzke, Christie Ballantyne, Christina Björklund, Christine Roraff, Christophe Laure, Christophe Thuaire, Christopher Chan, Christopher Fordyce, Christopher Kinsey, Chunli Xia, Cidney Schultz, Claes Held, Claudia Cortés, Claudia Escobar, Cláudia Freixo, Clemens T Kadalie, Corine Thobois, Courtney Page, Cristina Bare, Dalisa Espinosa, Dan Gao, Dana Rizk, Daniela Puzhevsky, Data Analyst, David M Charytan, David O Williams, David Booth, David Charytan, David Cohen, David DeMets, David Foo, David Goldfarb, David Schlichting, David Sisson, David Taggart, David Waters, David Wheeler, David Williams, Davis Vo, Dawid Teodorczyk, Dawn D Shelstad, Dean Kereiakes, Deborah Yip, Deepa Ramaswamy, Deirdre Mattina, Deirdre Murphy, Dengke Jiang, Derek Cyr, Diana Cukali, Diane Camara, Dimitrios Stournaras, Dipti Patel, Dongze Li, Donna Exley, Doreen Reimann, Doron Schwartz, Duarte Cacela, Dwayne S G Conway, Eapen Punnoose, Edgar L Tay, Edgar Karanjah, Eduardo Gomes Lima, Eduardo Hernandez-Rangel, Edward D Nicol, Edyta Kaczmarska, Elena Refoyo Salicio, Eli Feen, Elihú Durán-Cortés, Elisabeth M Janzen, Elise van Dongen, Elissa Restelli Piloto, Elizabeta Srbinovska Kostovska, Elizabeth Capasso-Gulve, Elizaveta V Zbyshevskaya, Ellie Fridell, Ellis W Lader, Elvira Gosmanova, Emilie Tachot, Emma Howard, Emmanuel Sorbets, Encarnación Alonso-Álvarez, Eric Daugas, Erick Alexánderson Rosas, Estelle Montpetit, Eugene Passamani, Evgeny Shutov, Ewa Szczerba, Ewelina Wojtala, Expedito Eustáquio Ribeiro Silva, Fabio Fimiani, Fadi Hage, Fahim Haider Jafary, Fang Feng, Fatima Ranjbaran, Fausto J Pinto, Fernando Caeiro, Fernando Nolasco, Filipa Silva, Filippo Ottani, Firas Al Solaiman, Flávia Egydio, Florina Chereches, Francesca De Micco, Francesca Bianchini, Francesca Pietrucci, Francesco Orso, Francesco Pisano, Francisca Patuleia Figueiras, François Madore, Frank Harrell, Frank Rockhold, Frans Van de Werf, Franziska Guenther, Fred Mohr, G Karthikeyan, Gabriel Galeote, Gabriel Grossmann, Gabriel Steg, Gabriela Guzman, Gabriele Gabrielli, Gang Chen, Gautam Sharma, Gaylin Petty, Gelmina Mikolaitiene, Gennie Yee, Gerard Patrick Devlin, Gerard Esposito, Gergely Ágoston, Gervasio Lamas, Gia Cobb, Gian Piero Perna, Gianpiero Leone, Girish Mishra, Gonzalo Barge-Caballero, Grace M Young, Graciela Scaro, Graham Wong, Gregg Pressman, Gregor Simonis, Gudrun Steinmaurer, Guilherme Portugal, Guilhermina Cantinho Lopes, Guillermo Garcia-Garcia, Guoqin Wang, Gurpreet S Wander, Gurpreet Gulati, Haibo Zhang, Halina Marciniak, Hao Dai, Haojian Dong, Harold Franch, Harvey White, Hatem Elabd, Hayley Pomeroy, Heather Golden, Heidi Wilson, Helene Abergel, Hemalata Siddaram, Hemant Shakhar Mahapatra, Henry C Stokes, Hermine Osseni, Herwig Schuchlenz, Hicham Skali, Holly Mattix-Kramer, Hong Cheng, Hossam Mahrous, Hristo Pejkov, Hugo Marques, Hui Zhong, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ikraam Hassan, Ileana L Pina, Ilona Tamasauskiene, Inês Zimbarra Cabrita, Ines Rodrigues, Inga Soveri, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Isabelle Roy, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, Jacek Kusmierek, Jackie Chow, Jaekyeong Heo, Jakub Maksym, James E Davies, James J Jang, James Hirsch, James Tatoulis, Jan Henzel, Janaina Oliveira, Janani Rangaswami, Jane Eckstein, Janitha Raj, Jaqueline Pozzibon, Jaroslaw Drozdz, Jason Loh Kwok Kong, Jason T Call, Jason Linefsky, Javier J Garcia, Jay Meisner, Jayne Scales, Jean Michel Juliard, Jean Diodati, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeff Leimberger, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Kanters, Jeffrey Lorin, Jeffrey Moses, Jelena J Stepanovic, Jelena Celutkiene, Jelena Stojkovic, Jenne M Jose, Jennifer L Stanford, Jennifer Hogan, Jennifer Horst, Jennifer Isaacs, Jennifer Thomson, Jennifer Tomfohr, Jennifer White, Jerry Yee, Jessica Berg, Jesus Peteiro, Jesús Peteiro, Jia Li, Jiamin Liu, Jianxin Zhang, Jill Marcus, Jim Blankenship, Jing Dong, Jiyan Chen, Jo Evans, Joaquín V Peñafiel, Joe Sabik, Johann Christopher, John B Kostis, John Joseph Graham, John Doan, John Jose, John Kotter, John Lehman, John Middleton, John Pownall, Jonathan M Gleadle, Jonathan S Chavez-Iñiguez, Jonathan Byrne, Jonathan Himmelfarb, Jonathan Lebowitz, Jonean Thorsen, Jorge Carrillo Calvillo, Jorge Escobedo, José A Ortega-Ramírez, José J Cuenca-Castillo, Jose L Diez, José Luis Narro Villanueva, José Luiz da Costa Vieira, José M Flores-Palacios, Jose Fragata, Jose Lopes, Jose Lopez-Sendon, José Lopez-Sendon, Jose Rueda, Joseph B Selvanayagam, Joseph Sacco, Joshua P Loh, Joy Burkhardt, Juan Manuel López Quijano, Juan Gaztanaga, Judit Sebo, Judith Wright, Juergen Stumpf, Julia de Aveiro Morata, Julio César Figal, Julio Hernandez Jaras, Junqing Yang, Jyotsna Garg, K Manjula Rani, K Preethi, Kaatje Goetschalckx, Karen Calfas, Karen Petrosyan, Karen Servilla, Karen Swan, Karin Ploetze, Karolina Kryczka, Karolina Wojtczak-Soska, Karolina Wojtera, Karthik Ramasamy, Katarzyna Łuczak, Katarzyna Malinowska, Katharina Knaut, Katherine Martin, Kathleen Claes, Kathryn Mason, Ken Mahaffey, Kenneth Gin, Kerry Lee, Kerstin Bonin, Kerstin Mikes, Kevin R Bainey, Kevin T Harley, Kevin Marzo, Kevin McMahon, Khaled Abdul-Nour, Khaled Alfakih, Khaled Dajani, Khrystyna Kushniriuk, Kian-Keong Poh, Kim Holland, Kimberly E Halverson, Kinnari Murphy, Kiran Reddy, Kirsten J Quiles, Kirsty Abercrombie, Klaus Matschke, Konrad Szymczyk, Koo Hui Chan, Kreton Mavromatis, Krishnakumar Hongalgi, Kristian Thygesen, Kristin M Salmi, Kristin Newby, Kristine Arges, Kristine Teoh, Krzysztof Drzymalski, Lalathaksha Kumbar, Laszlone Matics, LaTonya J Hickson, Laura Keinaite, Laura Sarti, Laura True, Lawrence M Phillips, Lawrence Friedman, Leandro C Maranan, Leda Lotaif, Lekshmi Dharmarajan, Leo A Bockeria, Leonardo Pizzol Caetano, Leonardo Bridi, Leonid L Bershtein, Li Hai Yan, Li Li, Lidia Sousa, Lihong Xu, Lihua Zhang, Lili Zhang, Lilian Mazza Barbosa, Liljana Tozija, Linda Arcand, Lino Patricio, Liping Zhang, Lisa Hatch, Lixin Jiang, Liz Low, Loay Salman, Lorena Lopez, Lori Pritchard, Luis Bernanrdes, Luis Guzman, Lynette L Teo, M Sowjanya Reddy, Maarten Simoons, Maayan Konigstein, Mafalda Selas, Magdalena Madero, Magdalena Miller, Magdalena Misztal-Teodorczyk, Magdy Abdelhamid, Magid Fahim, Mahevamma Mylarappa, Majo X Joseph, Malgorzata Frach, Manjula Rani, Marcello Galvani, Marcin Demkow, Marcin Szkopiak, Marco De Fabritis, Marco Magnoni, Marco Marini, Marco Sicuro, Marek Roik, Maria A Alfonso, Maria Antonieta Pereira de Moraes, María Dolores Martínez-Ruíz, Maria Eugenia Canziani, Maria Eugenia Martin, Maria Inês Caetano, Maria P Corral, Maria Pérez García, Maria Andreasson, Maria Posada, Marianna D A Dracoulakis, Mariano Rubio, Marija T Petrovic, Marina Vieira, Mario J Garcia, Mario D'arezzo, Maris Orgera, Marius Miglinas, Mark Garand, Mark Peterson, Mark Xavier, Marlowe Mosley, Marta Capinha, Marta Swiderek, Martha Meyer, Martina Ceseri, Martinia Tricoli, Mary Wiilliams, Mary Ann Champagne, Mary Streif, Massoud Leesar, Matei Claudia, Mateusz Solecki, Matías Nicolás Mungo, Matthew Shinseki, Matthew Weir, Maura Carina Nédio, Max-Paul Winter, Mayil S Krishnam, Meenakshi Mishra, Mei Hwang, Melemadathil Srilatha, Melissa LeFevre, Mengistu Simegn, Michael A Gibson, Michael B Rubens, Michael D Shapiro, Michael Chobanian, Michael Davidson, Michael Farkouh, Michael Mack, Michal Wlodarczyk, Michel G Khouri, Michelle Crowder, Michelle Ratliff, Miguel Borges Santos, Miguel Nobre Menezes, Miguel Perez Fontan, Miguel Barrero, Mihaly Tapolyai, Mikhail T Torosoff, Milan R Dobric, Milind Avdhoot Gadkari, Min Tun Kyaw, Miri Revivo, Mitchel B Lustre, Mohamed Adel, Mohamed Hassan, Mohammad El-Hajjar, Mohammed Hussain, Mohammed Saleem, Moisés Blanco-Calvo, Moisés Jiménez-Santos, Monika Laukyte, Muhamed Saric, Myrthes Emy Takiuti, Nadia Asif, Nagaraja Moorthy, Naima L Ogletree, Nana O Katamadze, Nandita Nataraj, Naomi Uchida, Nasrul Ismail, Natalia S Oliveira, Natalia de Carvalho Maffei, Nathalie Brosens, Naved Aslam, Naveed Akhtar, Neamat Mowafy, Neeraj Pandit, Neeraj Parakh, Neesh Pannu, Neill Duncan, Nevena Garcevic, Ngaire Meadows, Nicholas Danchin, Nicole Deming, Nikola N Boskovic, Nikolaos Karogiannis, Ning Zhang, Nirmal Kumar, Niruta Sharma, Nitika Chadha, Nitish Naik, Noelle M Durfee, Nora M Cosgrove, Norbert Urbanski, Norma Hogg, Olga Walesiak, Olga Zdończyk, Olga Zhdanova, Olivia Anaya, Olugbenga Bello, Omar Almousalli, Omar Thompson, Orit Kliuk, Oscar Méndiz, Óscar Prada-Delgado, Oz Shapira, Pablo Raffaele, Page Salanger, Pal Maurovich-Horvat, Pallav Garg, Paloma Moraga, Pam Singh, Pamela Ouyang, Pamela Woodard, Paola Emanuela Poggio Smanio, Paola Smanio, Paolo Calabro, Patricia K Nguyen, Patricia Alarie, Patricia Carrilho, Patricia Endsley, Patricia Pellikka, Patrycja Lebioda, Paul Der Mesropian, Paul Hauptman, Paula García-González, Paula Wilson, Paulo Cury Rezende, Paulo Novis Rocha, Pedro Canas Silva, Pedro Farto E Abreu, Pedro Píccaro de Oliveira, Pedro Carvalho, Pedro Modas, Pedro Rio, Peiyu He, Peter A McCullough, Peter H Stone, Peter Douglass, Peter Sizeland, Peter Voros, Philippe Gabriel Steg, Philippe Genereux, Philippe Généreux, Philippe Menasche, Philippe Rheault, Piero Tassinario, Pierre Gervais, Pilar Calvillo, Ping Chai, Piotr Jakubowski, Piotr Pruszczyk, Poay-Huan Loh, Pouneh Samadi, Prakash Deedwania, Pranav M Patel, Praneeth Polamuri, Pratiksha Sharma, Preeti Kamath, Prince Thomas, Priyadarshani Arambam, Puneet Sodhi, Pushpa Naik, Qi Zhong, Qian Zhao, Qianqian Yuan, Qiulan Xie, Rachel Murphy, Radmila Lyubarova, Radmilar Lyubarova, Raewyn Fisher, Rafael Diaz, Rafael Maldonado, Rafael Selgas, Raffaele Bugiardini, Rafia Chaudhry, Raisa Kavalakkat, Rajalekshmi Vs, Rajesh Gopalan Nair, Rajiv Narang, Rakesh Yadav, Ramiro Carvalho, Ramon de Jesús-Pérez, Ran Leng, Ranjan Kachru, Raquel Sanchez, Raven R Dwyer, Raven Lee, Ray Wyman, Raymond C Wong, Reinette Hampson, Renato Abdala Karam Kalil, Renato D Lopes, Renato George Eick, Renato Lopes, Reshma Ravindran, Reto Andreas Gamma, Ricardo Costa, Richa Bhatt, Richard H J Trimlett, Risha Patel, Rita Coram, Robert K Riezebos, Robert M Donnino, Robert Guyton, Robert Harrington, Robert Malecki, Roberto René Favaloro, Robyn Elliott, Rodolfo G S D Lima, Rohit Tandon, Rolf Doerr, Roma Tewari, Ron Wald, Rongrong Hu, Rory Collins, Roxana Mehran, Roxy Senior, Rubén Baleón-Espinosa, Ruben Ramos, Rui Ferreira, Ruth Kirby, Ruth Pérez-Fernández, S Ramakrishnan, S K Dwivedi, Sadath Lubna, Sadiq Ahmed, Sajeev Chakanalil Govindan, Salamah Alfalahi, Salvador Cruz-Flores, Salvatore P Costa, Sampoornima Setty, Samuel Nwosu, Sandeep Mahajan, Sandeep Seth, Sandeep Singh, Sander R Niehe, Sandy Carr, Sanja Simic Ogrizovic, Sanja Ogrizovic, Sanjeev Gulati, Sanjeev Sharma, Sara Fernandez, Sarah Williams, Sarju Ralhan, Sasko Kedev, Satinder Singh, Satish Sankaranarayanan, Satvic Cholenahally Manjunath, Sau Lee, Schawana Thaxton, Sean M O'Brien, Sebastian Sobczak, Seema Nour, Sergey A Sayganov, Sérgio Bravo Baptista, Sergio Draibe, Seth Sokol, Sharad Chandra, Shari Mackedanz, Shaun Goodman, Shayan Shirazian, Sheetal Rupesh Karwa, Sheri Ussery, Sheromani Bajaj, Shirin Heydari, Shiv Kumar Choudhary, Shivali Patel, Shruti Pandey, Shuyang Zhang, Siddharth Gadage, Sik-Yin V Tan, Sílvia Zottis Poletti, Silvia Valbuena, Simone Savaris, Solomon Yakubov, Songlin Zhu, Sonika Gupta, Sorin Brener, Sothinathan Gurunathan, Soundarya Nayak, Sowjanya Reddy, Stanley E Cobos, Stefan Weikl, Stephanie M Lane, Stephanie Ferket, Stephanie Mavromichalis, Stephen Fremes, Steven A Fein, Steven P Sedlis, Steven Giovannone, Steven Weitz, Subhash Banerjee, Sudhanva S Hegde, Suellen Hosino, Sulagna Mookherjee, Suman Singh, Sumith Abeygunasekara, Sundeep Mishra, Sunil Kumar Verma, Suresh Kumar, Suryaprakash Narayanappa, Susan K Milbrandt, Susana Silva, Susanna Stevens, Suvarna Kolhe, Suzana Tavares, Suzanne Welsh, T A Kishore, Tamara Colaiácovo Soares, Tapan Umesh Pillay, Tarek Rashid, Tarun K Mittal, Tauane Bello Duarte, Téodora Dutoiu, Teresa Delgadillo, Terrance Chua, Terrance Welch, Theodoros Kofidis, Thierry Lefevre, Tiago Silva, Timea Boros, Titus Lau, Tiziana Formisano, Tomasz Ciurus, Tomasz Tarchalski, Tracy Tan, Umesh Lingaraj, V K Bahl, V S Narain, Valentina Pellu, Valentine Lobo, Valerie Robesyn, Vandana Yadav, Veerabhadra Gupta, Verghese Mathew, Vicente Miro, Victoria Gumerova, Victoria Hernandez, Vijay Kher, Vijay Kumar, Vikas Makkar, Vikranth Reddy, Viktoria Bulkley, Vinoi George David, Virendra Misra, Virginia Fernández-Figares, Vladimir Ryasniansky, Vojislav L Giga, Wael A Almahmeed, Wan Xian Chan, Wanda C Marfori, Wanda Parker, Wayne Pennachi, Wei Ling Lau, Weibing Xing, Weijing Bian, Wendy L Stewart, Wendy Drewes, Whady Hueb, William Weintraub, Winnie C Sia, Xacobe Flores-Ríos, Xiang Ma, Xiangqiong Gu, Xiaomei Li, Xiaoyi Xu, Xin Fu, Xuemei Li, Xutong Wang, Yanek Pépin-Dubois, Yaron Arbel, Yechen Han, Yiming Lit, Ying Tung Sia, Ying Wang, Yining Yang, Yitong Ma, Yolayfi Peralta, Yves Smets, Yvonne Taul, Zalina Kudzoeva, Zeljko Z Markovic, Zhangsuo Liu, Zhenyu Liu, Zhiming Ye, Zixiang Yu, Zoltan Davidovits, Zvezdana Petronijevic, Spertus J.A., Jones P.G., Maron D.J., Mark D.B., O'Brien S.M., Fleg J.L., Reynolds H.R., Stone G.W., Sidhu M.S., Chaitman B.R., Chertow G.M., Hochman J.S., Bangalore S, and ISCHEMIA-CKD Research Group: Abdallah M Abdallah, Abel E Moreyra, Abhay A Laddu, Abhishek Dubey, Abhishek Goyal, Abigail Knighton, Adedayo Adeboye, Agne Juceviciene, Agne Urboniene, Agnieszka Szramowska, Ahmed Abdel-Latif, Ahmed Ayoub, Ahmed Elghamaz, Ahmed Kamal, Ahmed Talaat, Ajay Sharma, Ajit Singh Narula, Akshay Bagai, Akvile Smigelskaite, Alain Raymond, Alain Rheault, Alaine Melanie Loehr, Albert Varga, Aldo P Maggioni, Alec Moorman, Alejandro Chevaile Ramos, Alejandro Gisbert, Aleksandra Fratczak, Aleksandras Laucevicius, Alexander M Chernyavskiy, Alexander Sergeevich Borisov, Alexandra Craft, Alexandra Hunter, Alexandre Ciappina Hueb, Alexandre Schaan de Quadros, Alice Manica Muller, Aline Peixoto Deiro, Allegra Stone, Almudena Castro, Amar Uxa, Amaryllis Van Craenenbroeck, Ambuj Roy, Amit Kakkar, Amy Flowers, Amy Iskandrian, Ana D Djordjevic-Dikic, Ana Gomes Almeida, Ana Rita Francisco, Ana S Mladenovic, Ana Santana, Anandaroop Lahiri, Anastasia M Kuzmina-Krutetskaya, Anastasia Vamvakidou, Andras Vertes, Andre Gabriel, Andrea Bartykowszki, Andrea Lorimer, Andrea Pascual, Andreia Coelho, Andreia Rocha, Andrés García-Rincón, Andrew Starovoytov, Andrzej Łabyk, Anelise Kawakami, Angela Hoye, Angelo Nobre, Anjali Acharya, Anjali Anand, Anjana Rishmawi, Ann Banfield, Ann Luyten, Anna Cichocka-Radwan, Anna Fojt, Anna Plachcinska, Anna Teresinska, Anne Marie Webb, Anne Heath, Anoop Mathew, Antonia Vega, Antonio Carvalho, Antonio Colombo, Antonio Fiarresga, Anu Tharini, Anupama Rao, Aquiles Valdespino-Estrada, Ariel Diaz, Arif Asif, Arnold H Seto, Arturo S Campos-Santaolalla, Asim N Cheema, Asker Ahmed, Atul Mathur, Audrey W Leong, Axel Åkerblom, Axelle Fuentes, Aynun Naher, Badhma Valaiyapathi, Balaji Srinivasan, Baljeet Kaur, Balram Bhargava, Bandula Guruge, Barbara Wicklund, Bartosz Czarniak, Bebek Singh, Begoña Igual, Bela Merkely, Benoy N Shah, Bernard de Bruyne, Beth Abramson, Beth Stefanchik, Bethany Harvey, Bharati Shivalkar, Bilal Malik, Binoy Mannekkattukudy Kurian, Bougrida Hammouche, Branko D Beleslin, Bruce Ferguson, Bruce McManus, Bruna Maria Ascoli, Bryn Smith, Byron J Allen, C Michael Gibson, C Noel Bairey Merz, Calin Pop, Carl-Éric Gagné, Carly Ohmart, Carol M Kartje, Caroline Alsweiler, Caroline Rodgers, Caroline Spindler, Carolyn J Gruber, Catherine Albert, Catherine Bone, Catherine Lemay, Cezary Kepka, Chandini Suvarna, Chantale Mercure, Charlene Wiyarand, Chetan Patel, Chiara Attanasio, Chi-Ming Chow, Ching Min Er, Ching-Ching Ong, Cholenahally Nanjappa Manjunath, Chris Buller, Christel Vassaliere, Christiaan Vrints, Christian Witzke, Christie Ballantyne, Christina Björklund, Christine Roraff, Christophe Laure, Christophe Thuaire, Christopher Chan, Christopher Fordyce, Christopher Kinsey, Chunli Xia, Cidney Schultz, Claes Held, Claudia Cortés, Claudia Escobar, Cláudia Freixo, Clemens T Kadalie, Corine Thobois, Courtney Page, Cristina Bare, Dalisa Espinosa, Dan Gao, Dana Rizk, Daniela Puzhevsky, Data Analyst, David M Charytan, David O Williams, David Booth, David Charytan, David Cohen, David DeMets, David Foo, David Goldfarb, David Schlichting, David Sisson, David Taggart, David Waters, David Wheeler, David Williams, Davis Vo, Dawid Teodorczyk, Dawn D Shelstad, Dean Kereiakes, Deborah Yip, Deepa Ramaswamy, Deirdre Mattina, Deirdre Murphy, Dengke Jiang, Derek Cyr, Diana Cukali, Diane Camara, Dimitrios Stournaras, Dipti Patel, Dongze Li, Donna Exley, Doreen Reimann, Doron Schwartz, Duarte Cacela, Dwayne S G Conway, Eapen Punnoose, Edgar L Tay, Edgar Karanjah, Eduardo Gomes Lima, Eduardo Hernandez-Rangel, Edward D Nicol, Edyta Kaczmarska, Elena Refoyo Salicio, Eli Feen, Elihú Durán-Cortés, Elisabeth M Janzen, Elise van Dongen, Elissa Restelli Piloto, Elizabeta Srbinovska Kostovska, Elizabeth Capasso-Gulve, Elizaveta V Zbyshevskaya, Ellie Fridell, Ellis W Lader, Elvira Gosmanova, Emilie Tachot, Emma Howard, Emmanuel Sorbets, Encarnación Alonso-Álvarez, Eric Daugas, Erick Alexánderson Rosas, Estelle Montpetit, Eugene Passamani, Evgeny Shutov, Ewa Szczerba, Ewelina Wojtala, Expedito Eustáquio Ribeiro Silva, Fabio Fimiani, Fadi Hage, Fahim Haider Jafary, Fang Feng, Fatima Ranjbaran, Fausto J Pinto, Fernando Caeiro, Fernando Nolasco, Filipa Silva, Filippo Ottani, Firas Al Solaiman, Flávia Egydio, Florina Chereches, Francesca De Micco, Francesca Bianchini, Francesca Pietrucci, Francesco Orso, Francesco Pisano, Francisca Patuleia Figueiras, François Madore, Frank Harrell, Frank Rockhold, Frans Van de Werf, Franziska Guenther, Fred Mohr, G Karthikeyan, Gabriel Galeote, Gabriel Grossmann, Gabriel Steg, Gabriela Guzman, Gabriele Gabrielli, Gang Chen, Gautam Sharma, Gaylin Petty, Gelmina Mikolaitiene, Gennie Yee, Gerard Patrick Devlin, Gerard Esposito, Gergely Ágoston, Gervasio Lamas, Gia Cobb, Gian Piero Perna, Gianpiero Leone, Girish Mishra, Gonzalo Barge-Caballero, Grace M Young, Graciela Scaro, Graham Wong, Gregg Pressman, Gregor Simonis, Gudrun Steinmaurer, Guilherme Portugal, Guilhermina Cantinho Lopes, Guillermo Garcia-Garcia, Guoqin Wang, Gurpreet S Wander, Gurpreet Gulati, Haibo Zhang, Halina Marciniak, Hao Dai, Haojian Dong, Harold Franch, Harvey White, Hatem Elabd, Hayley Pomeroy, Heather Golden, Heidi Wilson, Helene Abergel, Hemalata Siddaram, Hemant Shakhar Mahapatra, Henry C Stokes, Hermine Osseni, Herwig Schuchlenz, Hicham Skali, Holly Mattix-Kramer, Hong Cheng, Hossam Mahrous, Hristo Pejkov, Hugo Marques, Hui Zhong, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ikraam Hassan, Ileana L Pina, Ilona Tamasauskiene, Inês Zimbarra Cabrita, Ines Rodrigues, Inga Soveri, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Isabelle Roy, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, Jacek Kusmierek, Jackie Chow, Jaekyeong Heo, Jakub Maksym, James E Davies, James J Jang, James Hirsch, James Tatoulis, Jan Henzel, Janaina Oliveira, Janani Rangaswami, Jane Eckstein, Janitha Raj, Jaqueline Pozzibon, Jaroslaw Drozdz, Jason Loh Kwok Kong, Jason T Call, Jason Linefsky, Javier J Garcia, Jay Meisner, Jayne Scales, Jean Michel Juliard, Jean Diodati, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeff Leimberger, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Kanters, Jeffrey Lorin, Jeffrey Moses, Jelena J Stepanovic, Jelena Celutkiene, Jelena Stojkovic, Jenne M Jose, Jennifer L Stanford, Jennifer Hogan, Jennifer Horst, Jennifer Isaacs, Jennifer Thomson, Jennifer Tomfohr, Jennifer White, Jerry Yee, Jessica Berg, Jesus Peteiro, Jesús Peteiro, Jia Li, Jiamin Liu, Jianxin Zhang, Jill Marcus, Jim Blankenship, Jing Dong, Jiyan Chen, Jo Evans, Joaquín V Peñafiel, Joe Sabik, Johann Christopher, John B Kostis, John Joseph Graham, John Doan, John Jose, John Kotter, John Lehman, John Middleton, John Pownall, Jonathan M Gleadle, Jonathan S Chavez-Iñiguez, Jonathan Byrne, Jonathan Himmelfarb, Jonathan Lebowitz, Jonean Thorsen, Jorge Carrillo Calvillo, Jorge Escobedo, José A Ortega-Ramírez, José J Cuenca-Castillo, Jose L Diez, José Luis Narro Villanueva, José Luiz da Costa Vieira, José M Flores-Palacios, Jose Fragata, Jose Lopes, Jose Lopez-Sendon, José Lopez-Sendon, Jose Rueda, Joseph B Selvanayagam, Joseph Sacco, Joshua P Loh, Joy Burkhardt, Juan Manuel López Quijano, Juan Gaztanaga, Judit Sebo, Judith Wright, Juergen Stumpf, Julia de Aveiro Morata, Julio César Figal, Julio Hernandez Jaras, Junqing Yang, Jyotsna Garg, K Manjula Rani, K Preethi, Kaatje Goetschalckx, Karen Calfas, Karen Petrosyan, Karen Servilla, Karen Swan, Karin Ploetze, Karolina Kryczka, Karolina Wojtczak-Soska, Karolina Wojtera, Karthik Ramasamy, Katarzyna Łuczak, Katarzyna Malinowska, Katharina Knaut, Katherine Martin, Kathleen Claes, Kathryn Mason, Ken Mahaffey, Kenneth Gin, Kerry Lee, Kerstin Bonin, Kerstin Mikes, Kevin R Bainey, Kevin T Harley, Kevin Marzo, Kevin McMahon, Khaled Abdul-Nour, Khaled Alfakih, Khaled Dajani, Khrystyna Kushniriuk, Kian-Keong Poh, Kim Holland, Kimberly E Halverson, Kinnari Murphy, Kiran Reddy, Kirsten J Quiles, Kirsty Abercrombie, Klaus Matschke, Konrad Szymczyk, Koo Hui Chan, Kreton Mavromatis, Krishnakumar Hongalgi, Kristian Thygesen, Kristin M Salmi, Kristin Newby, Kristine Arges, Kristine Teoh, Krzysztof Drzymalski, Lalathaksha Kumbar, Laszlone Matics, LaTonya J Hickson, Laura Keinaite, Laura Sarti, Laura True, Lawrence M Phillips, Lawrence Friedman, Leandro C Maranan, Leda Lotaif, Lekshmi Dharmarajan, Leo A Bockeria, Leonardo Pizzol Caetano, Leonardo Bridi, Leonid L Bershtein, Li Hai Yan, Li Li, Lidia Sousa, Lihong Xu, Lihua Zhang, Lili Zhang, Lilian Mazza Barbosa, Liljana Tozija, Linda Arcand, Lino Patricio, Liping Zhang, Lisa Hatch, Lixin Jiang, Liz Low, Loay Salman, Lorena Lopez, Lori Pritchard, Luis Bernanrdes, Luis Guzman, Lynette L Teo, M Sowjanya Reddy, Maarten Simoons, Maayan Konigstein, Mafalda Selas, Magdalena Madero, Magdalena Miller, Magdalena Misztal-Teodorczyk, Magdy Abdelhamid, Magid Fahim, Mahevamma Mylarappa, Majo X Joseph, Malgorzata Frach, Manjula Rani, Marcello Galvani, Marcin Demkow, Marcin Szkopiak, Marco De Fabritis, Marco Magnoni, Marco Marini, Marco Sicuro, Marek Roik, Maria A Alfonso, Maria Antonieta Pereira de Moraes, María Dolores Martínez-Ruíz, Maria Eugenia Canziani, Maria Eugenia Martin, Maria Inês Caetano, Maria P Corral, Maria Pérez García, Maria Andreasson, Maria Posada, Marianna D A Dracoulakis, Mariano Rubio, Marija T Petrovic, Marina Vieira, Mario J Garcia, Mario D'arezzo, Maris Orgera, Marius Miglinas, Mark Garand, Mark Peterson, Mark Xavier, Marlowe Mosley, Marta Capinha, Marta Swiderek, Martha Meyer, Martina Ceseri, Martinia Tricoli, Mary Wiilliams, Mary Ann Champagne, Mary Streif, Massoud Leesar, Matei Claudia, Mateusz Solecki, Matías Nicolás Mungo, Matthew Shinseki, Matthew Weir, Maura Carina Nédio, Max-Paul Winter, Mayil S Krishnam, Meenakshi Mishra, Mei Hwang, Melemadathil Srilatha, Melissa LeFevre, Mengistu Simegn, Michael A Gibson, Michael B Rubens, Michael D Shapiro, Michael Chobanian, Michael Davidson, Michael Farkouh, Michael Mack, Michal Wlodarczyk, Michel G Khouri, Michelle Crowder, Michelle Ratliff, Miguel Borges Santos, Miguel Nobre Menezes, Miguel Perez Fontan, Miguel Barrero, Mihaly Tapolyai, Mikhail T Torosoff, Milan R Dobric, Milind Avdhoot Gadkari, Min Tun Kyaw, Miri Revivo, Mitchel B Lustre, Mohamed Adel, Mohamed Hassan, Mohammad El-Hajjar, Mohammed Hussain, Mohammed Saleem, Moisés Blanco-Calvo, Moisés Jiménez-Santos, Monika Laukyte, Muhamed Saric, Myrthes Emy Takiuti, Nadia Asif, Nagaraja Moorthy, Naima L Ogletree, Nana O Katamadze, Nandita Nataraj, Naomi Uchida, Nasrul Ismail, Natalia S Oliveira, Natalia de Carvalho Maffei, Nathalie Brosens, Naved Aslam, Naveed Akhtar, Neamat Mowafy, Neeraj Pandit, Neeraj Parakh, Neesh Pannu, Neill Duncan, Nevena Garcevic, Ngaire Meadows, Nicholas Danchin, Nicole Deming, Nikola N Boskovic, Nikolaos Karogiannis, Ning Zhang, Nirmal Kumar, Niruta Sharma, Nitika Chadha, Nitish Naik, Noelle M Durfee, Nora M Cosgrove, Norbert Urbanski, Norma Hogg, Olga Walesiak, Olga Zdończyk, Olga Zhdanova, Olivia Anaya, Olugbenga Bello, Omar Almousalli, Omar Thompson, Orit Kliuk, Oscar Méndiz, Óscar Prada-Delgado, Oz Shapira, Pablo Raffaele, Page Salanger, Pal Maurovich-Horvat, Pallav Garg, Paloma Moraga, Pam Singh, Pamela Ouyang, Pamela Woodard, Paola Emanuela Poggio Smanio, Paola Smanio, Paolo Calabro, Patricia K Nguyen, Patricia Alarie, Patricia Carrilho, Patricia Endsley, Patricia Pellikka, Patrycja Lebioda, Paul Der Mesropian, Paul Hauptman, Paula García-González, Paula Wilson, Paulo Cury Rezende, Paulo Novis Rocha, Pedro Canas Silva, Pedro Farto E Abreu, Pedro Píccaro de Oliveira, Pedro Carvalho, Pedro Modas, Pedro Rio, Peiyu He, Peter A McCullough, Peter H Stone, Peter Douglass, Peter Sizeland, Peter Voros, Philippe Gabriel Steg, Philippe Genereux, Philippe Généreux, Philippe Menasche, Philippe Rheault, Piero Tassinario, Pierre Gervais, Pilar Calvillo, Ping Chai, Piotr Jakubowski, Piotr Pruszczyk, Poay-Huan Loh, Pouneh Samadi, Prakash Deedwania, Pranav M Patel, Praneeth Polamuri, Pratiksha Sharma, Preeti Kamath, Prince Thomas, Priyadarshani Arambam, Puneet Sodhi, Pushpa Naik, Qi Zhong, Qian Zhao, Qianqian Yuan, Qiulan Xie, Rachel Murphy, Radmila Lyubarova, Radmilar Lyubarova, Raewyn Fisher, Rafael Diaz, Rafael Maldonado, Rafael Selgas, Raffaele Bugiardini, Rafia Chaudhry, Raisa Kavalakkat, Rajalekshmi Vs, Rajesh Gopalan Nair, Rajiv Narang, Rakesh Yadav, Ramiro Carvalho, Ramon de Jesús-Pérez, Ran Leng, Ranjan Kachru, Raquel Sanchez, Raven R Dwyer, Raven Lee, Ray Wyman, Raymond C Wong, Reinette Hampson, Renato Abdala Karam Kalil, Renato D Lopes, Renato George Eick, Renato Lopes, Reshma Ravindran, Reto Andreas Gamma, Ricardo Costa, Richa Bhatt, Richard H J Trimlett, Risha Patel, Rita Coram, Robert K Riezebos, Robert M Donnino, Robert Guyton, Robert Harrington, Robert Malecki, Roberto René Favaloro, Robyn Elliott, Rodolfo G S D Lima, Rohit Tandon, Rolf Doerr, Roma Tewari, Ron Wald, Rongrong Hu, Rory Collins, Roxana Mehran, Roxy Senior, Rubén Baleón-Espinosa, Ruben Ramos, Rui Ferreira, Ruth Kirby, Ruth Pérez-Fernández, S Ramakrishnan, S K Dwivedi, Sadath Lubna, Sadiq Ahmed, Sajeev Chakanalil Govindan, Salamah Alfalahi, Salvador Cruz-Flores, Salvatore P Costa, Sampoornima Setty, Samuel Nwosu, Sandeep Mahajan, Sandeep Seth, Sandeep Singh, Sander R Niehe, Sandy Carr, Sanja Simic Ogrizovic, Sanja Ogrizovic, Sanjeev Gulati, Sanjeev Sharma, Sara Fernandez, Sarah Williams, Sarju Ralhan, Sasko Kedev, Satinder Singh, Satish Sankaranarayanan, Satvic Cholenahally Manjunath, Sau Lee, Schawana Thaxton, Sean M O'Brien, Sebastian Sobczak, Seema Nour, Sergey A Sayganov, Sérgio Bravo Baptista, Sergio Draibe, Seth Sokol, Sharad Chandra, Shari Mackedanz, Shaun Goodman, Shayan Shirazian, Sheetal Rupesh Karwa, Sheri Ussery, Sheromani Bajaj, Shirin Heydari, Shiv Kumar Choudhary, Shivali Patel, Shruti Pandey, Shuyang Zhang, Siddharth Gadage, Sik-Yin V Tan, Sílvia Zottis Poletti, Silvia Valbuena, Simone Savaris, Solomon Yakubov, Songlin Zhu, Sonika Gupta, Sorin Brener, Sothinathan Gurunathan, Soundarya Nayak, Sowjanya Reddy, Stanley E Cobos, Stefan Weikl, Stephanie M Lane, Stephanie Ferket, Stephanie Mavromichalis, Stephen Fremes, Steven A Fein, Steven P Sedlis, Steven Giovannone, Steven Weitz, Subhash Banerjee, Sudhanva S Hegde, Suellen Hosino, Sulagna Mookherjee, Suman Singh, Sumith Abeygunasekara, Sundeep Mishra, Sunil Kumar Verma, Suresh Kumar, Suryaprakash Narayanappa, Susan K Milbrandt, Susana Silva, Susanna Stevens, Suvarna Kolhe, Suzana Tavares, Suzanne Welsh, T A Kishore, Tamara Colaiácovo Soares, Tapan Umesh Pillay, Tarek Rashid, Tarun K Mittal, Tauane Bello Duarte, Téodora Dutoiu, Teresa Delgadillo, Terrance Chua, Terrance Welch, Theodoros Kofidis, Thierry Lefevre, Tiago Silva, Timea Boros, Titus Lau, Tiziana Formisano, Tomasz Ciurus, Tomasz Tarchalski, Tracy Tan, Umesh Lingaraj, V K Bahl, V S Narain, Valentina Pellu, Valentine Lobo, Valerie Robesyn, Vandana Yadav, Veerabhadra Gupta, Verghese Mathew, Vicente Miro, Victoria Gumerova, Victoria Hernandez, Vijay Kher, Vijay Kumar, Vikas Makkar, Vikranth Reddy, Viktoria Bulkley, Vinoi George David, Virendra Misra, Virginia Fernández-Figares, Vladimir Ryasniansky, Vojislav L Giga, Wael A Almahmeed, Wan Xian Chan, Wanda C Marfori, Wanda Parker, Wayne Pennachi, Wei Ling Lau, Weibing Xing, Weijing Bian, Wendy L Stewart, Wendy Drewes, Whady Hueb, William Weintraub, Winnie C Sia, Xacobe Flores-Ríos, Xiang Ma, Xiangqiong Gu, Xiaomei Li, Xiaoyi Xu, Xin Fu, Xuemei Li, Xutong Wang, Yanek Pépin-Dubois, Yaron Arbel, Yechen Han, Yiming Lit, Ying Tung Sia, Ying Wang, Yining Yang, Yitong Ma, Yolayfi Peralta, Yves Smets, Yvonne Taul, Zalina Kudzoeva, Zeljko Z Markovic, Zhangsuo Liu, Zhenyu Liu, Zhiming Ye, Zixiang Yu, Zoltan Davidovits, Zvezdana Petronijevic

Subjects
Male, Intention to Treat Analysi, medicine.medical_treatment, Health Status, Myocardial Ischemia, 030204 cardiovascular system & hematology, Coronary Angiography, law.invention, Health Statu, 0302 clinical medicine, Randomized controlled trial, law, Surveys and Questionnaires, Odds Ratio, Surveys and Questionnaire, 030212 general & internal medicine, Myocardial infarction, Coronary Artery Bypass, medicine.diagnostic_test, General Medicine, Middle Aged, Intention to Treat Analysis, Cardiology, Female, Human, medicine.medical_specialty, Revascularization, Follow-Up Studie, 03 medical and health sciences, Percutaneous Coronary Intervention, Internal medicine, medicine, Humans, cardiovascular diseases, Healthy Lifestyle, Renal Insufficiency, Chronic, Proportional Hazards Models, Aged, Intention-to-treat analysis, business.industry, Coronary Artery Bypa, Percutaneous coronary intervention, Odds ratio, medicine.disease, Angiography, Exercise Test, Proportional Hazards Model, business, Kidney disease, Follow-Up Studies
Abstract

BACKGROUND In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of

Published
2020

43. A retrospective multi‐center experience of renal transplants from India during COVID‐19 pandemic

Author

Ashwini Gadde, S Pokhariyal, Prasun Ghosh, Dinesh Bansal, Ashish Nandwani, Feroz Amir Zafar, Rajesh Ahlawat, Puneet Sodhi, Vijay Kher, Sidharth Kumar Sethi, Tarun Jeloka, Vishwanath Siddini, Shyam Bihari Bansal, Manish Jain, Rohan Augustine, Salil Jain, Pranaw Kumar Jha, Urmila Anandh, R. K. Sharma, V Saxena, Aseem K Tiwari, Sreedhar Reddy, and Dinesh Kumar Yadav

Subjects
Pediatrics, medicine.medical_specialty, coronavirus, India, kidney transplantation, Logistic regression, Asymptomatic, SARS‐CoV‐2, Median follow-up, COVID‐19, Case fatality rate, Pandemic, medicine, Humans, Pandemics, Kidney transplantation, Aged, Retrospective Studies, Transplantation, business.industry, SARS-CoV-2, Incidence (epidemiology), pandemic, COVID-19, Odds ratio, Original Articles, medicine.disease, Communicable Disease Control, Original Article, medicine.symptom, business
Abstract

Introduction Coronavirus disease 2019 (COVID-19) pandemic led to a sudden drop in renal transplant numbers across India in the initial months of 2020. Although the transplant numbers increased with easing of lockdown, the outcome of these transplants remains unknown. Methods This was a retrospective, observational, multi-center study done across 8 different transplant centers in India. All the transplants done from 30/01/2020 till 31/12/2020 were included. The primary outcomes studied were patient and death censored graft survival as well as incidence of COVID-19 infection and its outcomes. Results During the study period a total of 297 kidney transplants were done. After a median follow up of 265 days the patient and death censored graft survival was 95.3% and 97.6% respectively. Forty-one patients (13.8%) developed COVID-19 post-transplant. Majority (58.5%) were asymptomatic to mildly symptomatic and the case fatality ratio was 14.6%. On multivariable logistic regression analysis older age was associated with higher likelihood of COVID-19 infection (odds ratio 1.038; CI 1.002 to 1.077). Conclusions Patient and graft outcome of kidney transplants done during the COVID-19 pandemic in India was acceptable. The incidence of COVID-19 was 13.8% with a high case fatality ratio. This article is protected by copyright. All rights reserved.

Published
2021

44. Peritoneal dialysis: Status report in South and South East Asia

Author

Vivekanand Jha, Santosh Varughese, Suceena Alexander, Lina H-L Choong, Sanjiv Jasuja, Chih Ching Lin, Sampathkumar Krishnaswamy, Amit Gupta, Maurizio Gallieni, Goh Bak Leong, Khin Thida Thwin, Vinant Bhargava, Anupam Bahl, Atma Gunawan, Mamun Mostafi, Umesh Khanna, Roberto Tanchanco, Syed Fazal Akhtar, Ali AlSahow, Mohan Rajapurkar, Kriengsak Vareesangthip, Sydney C.W. Tang, Manisha Sahay, Chula Herath, Devender Singh Rana, Rajendra Kumar Agrawal, Raja Ramachandran, Anil Kumar Bhalla, Tushar J. Vachharajani, Jayakrishnan K. Pisharam, Shalini Verma, Vijay Kher, Ashwani Gupta, Gaurav Sagar, Aida Lydia, and Chakko K. Jacob

Subjects
medicine.medical_specialty, Health Knowledge, Attitudes, Practice, Asia, Attitude of Health Personnel, medicine.medical_treatment, Gross Domestic Product, Peritoneal dialysis, Nephrologists, medicine, Humans, South east asia, Practice Patterns, Physicians', Policy Making, Socioeconomic status, Developing Countries, Reimbursement, Dialysis, Modalities, business.industry, Health Policy, General Medicine, Status report, Incentive, Nephrology, Family medicine, Health Care Surveys, Income, Kidney Diseases, Health Expenditures, business, Peritoneal Dialysis, Forecasting
Abstract

Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SASEA) region.The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HIHMI) and low income and lower-middle income (LILMI) groups.Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HIHMI -US$ 28 129 vs. LILMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LILMI countries, they have poorer PD utilization as compared to HIHMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization.Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Published
2021

45. Identification of PKD1 and PKD2 gene variants in a cohort of 125 Asian Indian patients of ADPKD

Author

Jyotsna Verma, Renu Saxena, Arndt Rolfs, Sabrina Eichler, Sudha Kohli, Shewata Pandita, Dinesh Khullar, Anil Kumar Bhalla, Oliver Brandau, Ishwar Chander Verma, Prahlad Balakrishnan, Vindu Amitabh, Sivaramakrishnan Ramanarayanan, Vijay Kher, and Vijaya Ramachandran

Subjects
Adult, Male, 0301 basic medicine, TRPP Cation Channels, Adolescent, Genetic Linkage, Autosomal dominant polycystic kidney disease, India, 030105 genetics & heredity, Biology, urologic and male genital diseases, 03 medical and health sciences, Genetic linkage, Genotype, Genetic variation, Genetics, medicine, Humans, Multiplex ligation-dependent probe amplification, Gene, Genetics (clinical), Aged, Aged, 80 and over, PKD1, urogenital system, Genetic Variation, Middle Aged, Polycystic Kidney, Autosomal Dominant, medicine.disease, female genital diseases and pregnancy complications, 030104 developmental biology, Female, Kidney disease
Abstract

Autosomal Dominant Polycystic Kidney Disease (ADPKD) accounts for 2.6% of the patients with chronic kidney disease in India. ADPKD is caused by pathogenic variants in either PKD1 or PKD2 gene. There is no comprehensive genetic data from Indian subcontinent. We aimed to identify the pathogenic variants in the heterogeneous Indian population. PKD1 and PKD2 variants were identified by direct gene sequencing and/or multiplex ligation-dependent probe amplification (MLPA) in 125 unrelated patients of ADPKD. The pathogenic potential of the variants was evaluated computationally and were classified according to ACMG guidelines. Overall 300 variants were observed in PKD1 and PKD2 genes, of which 141 (47%) have been reported previously as benign. The remaining 159 variants were categorized into different classes based on their pathogenicity. Pathogenic variants were observed in 105 (84%) of 125 patients, of which 99 (94.3%) were linked to PKD1 gene and 6 (6.1%) to PKD2 gene. Of 159 variants, 97 were novel variants, of which 43 (44.33%) were pathogenic, and 10 (10.31%) were of uncertain significance. Our data demonstrate the diverse genotypic makeup of single gene disorders in India as compared to the West. These data would be valuable in counseling and further identification of probable donors among the relatives of patients with ADPKD.

Published
2019

46. Interventional nephrology and vascular access practice: A perspective from South and Southeast Asia

Author

Raja Ramachandran, Vinant Bhargava, Sanjiv Jasuja, Maurizio Gallieni, Vivekanand Jha, Manisha Sahay, Suceena Alexender, Mamun Mostafi, Jayakrishnan K Pisharam, Tang Sydeny Chi Wai, Chakko Jacob, Atma Gunawan, Goh Bak Leong, Khin Thida Thwin, Rajendra Kumar Agrawal, Kriengsak Vareesangthip, Roberto Tanchanco, Lina Choong, Chula Herath, Chih-Ching Lin, Nguyen The Cuong, Syed Fazal Akhtar, Ali Alsahow, D S Rana, Vijay Kher, M M Rajapurkar, L Jeyaseelan, Sonika Puri, Gaurav Sagar, Anupam Bahl, Shalini Verma, Anil Sethi, and Tushar Vachharajani

Subjects
medicine.medical_specialty, Catheter insertion, medicine.diagnostic_test, business.industry, medicine.medical_treatment, Fistula, Vascular access, medicine.disease, Southeast asia, Peritoneal dialysis, Nephrologists, Arteriovenous Shunt, Surgical, Nephrology, Renal Dialysis, Internal medicine, Epidemiology, medicine, Humans, Kidney Failure, Chronic, Surgery, Renal biopsy, Hemodialysis, business, Asia, Southeastern
Abstract

South and Southeast Asia is the most populated, heterogeneous part of the world. The Association of Vascular Access and InTerventionAl Renal physicians (AVATAR Foundation), India, gathered trends on epidemiology and Interventional Nephrology (IN) for this region. The countries were divided as upper-middle- and higher-income countries as Group-1 and lower and lower-middle-income countries as Group-2. Forty-three percent and 70% patients in the Group 1 and 2 countries had unplanned hemodialysis (HD) initiation. Among the incident HD patients, the dominant Vascular Access (VA) was non-tunneled central catheter (non-TCC) in 70% of Group 2 and tunneled central catheter (TCC) in 32.5% in Group 1 countries. Arterio-Venous Fistula (AVF) in the incident HD patients was observed in 24.5% and 35% of patients in Group-2 and Group-1, respectively. Eight percent and 68.7% of the prevalent HD patients in Group-2 and Group-1 received HD through an AVF respectively. Nephrologists performing any IN procedure were 90% and 60% in Group-2 and Group 1, respectively. The common procedures performed by nephrologists include renal biopsy (93.3%), peritoneal dialysis (PD) catheter insertion (80%), TCC (66.7%) and non-TCC (100%). Constraints for IN include lack of time (73.3%), lack of back-up (40%), lack of training (73.3%), economic issues (33.3%), medico-legal problems (46.6%), no incentive (20%), other interests (46.6%) and institution not supportive (26%). Routine VA surveillance is performed in 12.5% and 83.3% of Group-2 and Group-1, respectively. To conclude, non-TCC and TCC are the most common vascular access in incident HD patients in Group-2 and Group-1, respectively. Lack of training, back-up support and economic constraints were main constraints for IN growth in Group-2 countries.

Published
2021

47. Impact of National Economy and Policies on End-Stage Kidney Care in South Asia and Southeast Asia

Author

Khin Thida Thwin, Atma Gunawan, Mohan Rajapurkar, Sonika Puri, Sanjiv Jasuja, Chih C Lin, Devender Singh Rana, Tushar J. Vachharajani, Chula Herath, Ha Phan Haian, Deepak Shankar Ray, Roberto Tanchanco, Sydney C.W. Tang, Anil Kumar Bhalla, Nguyen T Cuong, Aida Lydia, Maurizio Gallieni, Goh Bak Leong, Chakko K. Jacob, Vinant Bhargava, Hemant Mehta, Suceena Alexander, Ali AlSahow, Kriengsak Vareesangthip, Manisha Sahay, Anupam Bahl, Lina H-L Choong, Syed Fazal Akhtar, Vivekanand Jha, Mamun Mostafi, Umesh Khanna, Gaurav Sagar, Rajendra Kumar Agrawal, Raja Ramachandran, Himanshu Jain, Shalini Verma, Jayakrishnan K. Pisharam, and Vijay Kher

Subjects
National Economy, Nephrology, kidney, medicine.medical_specialty, medicine.medical_treatment, Population, Review Article, South Asia, End stage renal disease, Internal medicine, kidney Care, medicine, Renal replacement therapy, education, Dialysis, education.field_of_study, business.industry, Incidence (epidemiology), End Stage, medicine.disease, Southeast Asia, Diseases of the genitourinary system. Urology, Policy, impact, Hemodialysis, RC870-923, business, Demography, Kidney disease
Abstract

Background. The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). Methods. Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. Results. Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and 10% in all the HE countries except Taiwan, 10%–20% in the majority of LE countries. Conclusion. Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.

Published
2020

48. INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease

Author

Radha K. Dhiman, Narendra S. Choudhary, Santosh Varughese, Shivaram Prasad Singh, Manish Rathi, Vijay Kher, R. P. Mathur, Sanjay K. Agarwal, Rakhi Maiwall, Umapati Hegde, Sree B. Raju, Vinod Kumar Dixit, S. Nayak, Shalimar, Sanjiv Jasuja, Anil C. Anand, Anil Arora, Gaurav Pandey, Ramesh R. Rai, Rakesh Aggarwal, Praveen Sharma, Kaushal Madan, Natarajan Gopalakrishnan, Rajendra Pandey, Devinder Singh Rana, Ajay Kumar, Sunil Taneja, Ashwani Gupta, Anil Kumar Bhalla, Vivek Jha, Arvinder S. Soin, Sanjiv Saxena, Ashok Kumar, Pankaj Puri, Vivek A. Saraswat, Narayan Prasad, Padaki Nagaraja Rao, YK Chawla, Subrat K. Acharya, Ashwani K. Singal, and Ajay Duseja

Subjects
Nephrology, medicine.medical_specialty, Cirrhosis, Hepatology, business.industry, Acute kidney injury, Disease, Chronic liver disease, medicine.disease, 03 medical and health sciences, Liver disease, 0302 clinical medicine, Hepatorenal syndrome, 030220 oncology & carcinogenesis, Internal medicine, medicine, 030211 gastroenterology & hepatology, Clinical Practice Guidelines, business, Intensive care medicine, Kidney disease
Abstract

Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20–21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

Published
2020

49. COVID-19 in Renal Transplant Recipients - A Single Center Experience from India

Author

PranawKumar Jha, Saurabh Shukla, Dinesh Bansal, ShyamBihari Bansal, Sidharth Sethi, Manish Jain, DineshKumar Yadav, Ashwini Gadde, AmitKumar Mahapatra, Puneet Sodhi, and Vijay Kher

Subjects
Nephrology
Abstract

The information on the clinical outcome of renal transplant recipients getting COVID-19 infection is sparse. The aim of this study is to report a single-center experience of renal transplant recipients with COVID-19 from India.This was a retrospective study of 23 consecutive renal transplant recipients with COVID-19 infection presenting to our center from May 2020 to August 2020. Clinical parameters, laboratory values, imaging characteristics, and outcome of the patients were collected and analyzed.Median follow-up duration was 36 (range: 10-110) days. Median age of patients was 54 (23-70) years, and 87% were male. Median duration since transplant was 69 (range: 15-132) months. The most common presenting feature was fever (82.6%), followed by breathlessness (43.5%) and cough (30.4%). Hospitalization rate was 52.2%, while 34.8% required ICU care. Severe to critical disease was seen in 39.1% of patients, and 17.4% required mechanical ventilation. Patients with severe disease had a higher incidence of lymphopenia (Renal transplant recipients with COVID-19 have a poor outcome. Although not all of them need hospitalization, they should be monitored closely. Immunosuppression minimization is an important part of the treatment strategy.

Published
2020

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