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Dennhardt S, Ceanga IA, Baumbach P, Amiratashani M, Kröller S, Coldewey SM. Cell-free DNA in patients with sepsis: long term trajectory and association with 28-day mortality and sepsis-associated acute kidney injury. Front Immunol 2024; 15:1382003. [PMID: 38803503 PMCID: PMC11128621 DOI: 10.3389/fimmu.2024.1382003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/09/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Outcome-prediction in patients with sepsis is challenging and currently relies on the serial measurement of many parameters. Standard diagnostic tools, such as serum creatinine (SCr), lack sensitivity and specificity for acute kidney injury (AKI). Circulating cell-free DNA (cfDNA), which can be obtained from liquid biopsies, can potentially contribute to the quantification of tissue damage and the prediction of sepsis mortality and sepsis-associated AKI (SA-AKI). Methods We investigated the clinical significance of cfDNA levels as a predictor of 28-day mortality, the occurrence of SA-AKI and the initiation of renal replacement therapy (RRT) in patients with sepsis. Furthermore, we investigated the long-term course of cfDNA levels in sepsis survivors at 6 and 12 months after sepsis onset. Specifically, we measured mitochondrial DNA (mitochondrially encoded NADH-ubiquinone oxidoreductase chain 1, mt-ND1, and mitochondrially encoded cytochrome C oxidase subunit III, mt-CO3) and nuclear DNA (nuclear ribosomal protein S18, n-Rps18) in 81 healthy controls and all available samples of 150 intensive care unit patients with sepsis obtained at 3 ± 1 days, 7 ± 1 days, 6 ± 2 months and 12 ± 2 months after sepsis onset. Results Our analysis revealed that, at day 3, patients with sepsis had elevated levels of cfDNA (mt-ND1, and n-Rps18, all p<0.001) which decreased after the acute phase of sepsis. 28-day non-survivors of sepsis (16%) had higher levels of cfDNA (all p<0.05) compared with 28-day survivors (84%). Patients with SA-AKI had higher levels of cfDNA compared to patients without AKI (all p<0.05). Cell-free DNA was also significantly increased in patients requiring RRT (all p<0.05). All parameters improved the AUC for SCr in predicting RRT (AUC=0.88) as well as APACHE II in predicting mortality (AUC=0.86). Conclusion In summary, cfDNA could potentially improve risk prediction models for mortality, SA-AKI and RRT in patients with sepsis. The predictive value of cfDNA, even with a single measurement at the onset of sepsis, could offer a significant advantage over conventional diagnostic methods that require repeated measurements or a baseline value for risk assessment. Considering that our data show that cfDNA levels decrease after the first insult, future studies could investigate cfDNA as a "memoryless" marker and thus bring further innovation to the complex field of SA-AKI diagnostics.
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Affiliation(s)
- Sophie Dennhardt
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Iuliana-Andreea Ceanga
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Mona Amiratashani
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Sarah Kröller
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Sina M. Coldewey
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
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Kotani Y, Landoni G, Zarbock A, Bellomo R. Acute kidney injury data collection in intensive care trials: hurdles and solutions. Minerva Anestesiol 2023; 89:845-847. [PMID: 37526468 DOI: 10.23736/s0375-9393.23.17505-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy -
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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Contreras-Villamizar K, Barbosa O, Muñoz AC, Suárez JS, González CA, Vargas DC, Rodríguez-Sánchez MP, García-Padilla P, Valderrama-Rios MC, Cortés JA. Risk factors associated with acute kidney injury in a cohort of hospitalized patients with COVID-19. BMC Nephrol 2023; 24:140. [PMID: 37217840 DOI: 10.1186/s12882-023-03172-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Patients with COVID-19 have a high incidence of acute kidney injury (AKI), which is associated with mortality. The objective of the study was to determine the factors associated with AKI in patients with COVID-19. METHODOLOGY A retrospective cohort was established in two university hospitals in Bogotá, Colombia. Adults hospitalized for more than 48 h from March 6, 2020, to March 31, 2021, with confirmed COVID-19 were included. The main outcome was to determine the factors associated with AKI in patients with COVID-19 and the secondary outcome was estimate the incidence of AKI during the 28 days following hospital admission. RESULTS A total of 1584 patients were included: 60.4% were men, 738 (46.5%) developed AKI, 23.6% were classified as KDIGO 3, and 11.1% had renal replacement therapy. The risk factors for developing AKI during hospitalization were male sex (OR 2.28, 95% CI 1.73-2.99), age (OR 1.02, 95% CI 1.01-1.03), history of chronic kidney disease (CKD) (OR 3.61, 95% CI 2.03-6.42), High Blood Pressure (HBP) (OR 6.51, 95% CI 2.10-20.2), higher qSOFA score to the admission (OR 1.4, 95% CI 1.14-1.71), the use of vancomycin (OR 1.57, 95% CI 1.05-2.37), piperacillin/tazobactam (OR 1.67, 95% CI 1.2-2.31), and vasopressor support (CI 2.39, 95% CI 1.53-3.74). The gross hospital mortality for AKI was 45.5% versus 11.7% without AKI. CONCLUSIONS This cohort showed that male sex, age, history of HBP and CKD, presentation with elevated qSOFA, in-hospital use of nephrotoxic drugs and the requirement for vasopressor support were the main risk factors for developing AKI in patients hospitalized for COVID-19.
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Affiliation(s)
- Kateir Contreras-Villamizar
- Nephrology Unit, Kr 7 40 62 Hospital Universitario San Ignacio, 110231, Bogotá, DC, Colombia.
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia.
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá Campus, Bogotá, DC, Colombia.
| | - Oscar Barbosa
- Nephrology Unit, Kr 7 40 62 Hospital Universitario San Ignacio, 110231, Bogotá, DC, Colombia
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Ana Cecilia Muñoz
- Nephrology Unit, Kr 7 40 62 Hospital Universitario San Ignacio, 110231, Bogotá, DC, Colombia
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Juan Sebastián Suárez
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá Campus, Bogotá, DC, Colombia
- Infectology Unit, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia
| | - Camilo A González
- Nephrology Unit, Kr 7 40 62 Hospital Universitario San Ignacio, 110231, Bogotá, DC, Colombia
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Diana Carolina Vargas
- Nephrology Unit, Kr 7 40 62 Hospital Universitario San Ignacio, 110231, Bogotá, DC, Colombia
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Martha Patricia Rodríguez-Sánchez
- Nephrology Unit, Kr 7 40 62 Hospital Universitario San Ignacio, 110231, Bogotá, DC, Colombia
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Paola García-Padilla
- Nephrology Unit, Kr 7 40 62 Hospital Universitario San Ignacio, 110231, Bogotá, DC, Colombia
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | | | - Jorge Alberto Cortés
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá Campus, Bogotá, DC, Colombia
- Infectology Unit, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia
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Gudivada KK, Narayan SK, Narasimha A, Krishna B, Muralidhara KD. Evaluation of Predictors, Kinetics of Renal Recovery and Outcomes of COVID-19 Patients with Acute Kidney Injury Admitted to Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2022; 26:1293-1299. [PMID: 36755632 PMCID: PMC9886020 DOI: 10.5005/jp-journals-10071-24372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
Background The incidence of acute kidney injury (AKI) is greater than 50% among coronavirus disease-2019 (COVID-19) patients admitted to the intensive care unit (ICU). However, the literature on predictors and kinetics of renal recovery remains unclear. Patients and methods This observational study was conducted in a 30-bedded mixed ICU of a tertiary care center from May 2020 to July 2021. A total of 200 consecutive adult COVID-19 patients who had AKI in ICU were included. Using logistic regression with the best subset selection, predictors of renal recovery were identified. Outcomes and kinetics of AKI recovery were determined. Results Among 200 patients, 67 recovered from AKI, of which 38, 17, and 12 patients had transient AKI, persistent AKI, and acute kidney disease (AKD), respectively. A total of 25 patients had AKI relapse, primarily associated with hospital-acquired infections. Results of logistic regression showed that the combination of Acute Physiology and Chronic Health Evaluation (APACHE II) {odds ratio (OR) 1.1 [p < 0.001; 95% confidence interval (CI) 1.06-1.16]}, day onset of AKI [OR 1.6 (p = 0.001; 1.24-2.24)] and severity of AKI [OR 2.9 (p < 0.001; 2.03-4.36)] were the predictors associated with poor renal recovery. This model had sufficient discrimination with the area under the curve (AUC) of 0.86. Renal replacement therapy requirement and mortality among COVID-AKI patients were 68 and 84%, respectively. Conclusion A higher APACHE II at admission, a longer time to onset of AKI, and the severity of AKI during ICU stay predicted poor renal recovery. Study results emphasize the need for stepping-up dialysis resources in the likely case of future waves of COVID-19. The relapse of AKI was associated with sepsis, and mortality rates were substantially high. How to cite this article Gudivada KK, Narayan SK, Narasimha A, Krishna B, Muralidhara KD. Evaluation of Predictors, Kinetics of Renal Recovery and Outcomes of COVID-19 Patients with Acute Kidney Injury Admitted to Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2022;26(12):1293-1299.
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Affiliation(s)
- Kiran Kumar Gudivada
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Hyderabad Metropolitan Region, Telangana, India,Kiran Kumar Gudivada, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Hyderabad Metropolitan Region, Telangana, India, Phone: +91 9490887406, e-mail:
| | - Shiva Kumar Narayan
- Department of Critical Care Medicine, St. John's Medical College, Bengaluru, Karnataka, India
| | - Alok Narasimha
- Department of Critical Care Medicine, St. John's Medical College, Bengaluru, Karnataka, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St. John's Medical College, Bengaluru, Karnataka, India
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Jensen SK, Heide-Jørgensen U, Vestergaard SV, Gammelager H, Birn H, Nitsch D, Christiansen CF. Kidney function before and after acute kidney injury: a nationwide population-based cohort study. Clin Kidney J 2022; 16:484-493. [PMID: 36865015 PMCID: PMC9972836 DOI: 10.1093/ckj/sfac247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Indexed: 11/19/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common and serious condition defined by a rapid decline in kidney function. Data on changes in long-term kidney function following AKI are sparse and conflicting. Therefore, we examined the changes in estimated glomerular filtration rate (eGFR) from before to after AKI in a nationwide population-based setting. Methods Using Danish laboratory databases, we identified individuals with first-time AKI defined by an acute increase in plasma creatinine (pCr) during 2010 to 2017. Individuals with three or more outpatient pCr measurements before and after AKI were included and cohorts were stratified by baseline eGFR (≥/<60 mL/min/1.73 m2). Linear regression models were used to estimate and compare individual eGFR slopes and eGFR levels before and after AKI. Results Among individuals with a baseline eGFR ≥60 mL/min/1.73 m2 (n = 64 805), first-time AKI was associated with a median difference in eGFR level of -5.6 mL/min/1.73 m2 [interquartile range (IQR) -16.1 to 1.8] and a median difference in eGFR slope of -0.4 mL/min/1.73 m2/year (IQR -5.5 to 4.4). Correspondingly, among individuals with a baseline eGFR <60 mL/min/1.73 m2 (n = 33 267), first-time AKI was associated with a median difference in eGFR level of -2.2 mL/min/1.73 m2 (IQR -9.2 to 4.3) and a median difference in eGFR slope of 1.5 mL/min/1.73 m2/year (IQR -2.9 to 6.5). Conclusion Among individuals with first-time AKI surviving to have repeated outpatient pCr measurements, AKI was associated with changes in eGFR level and eGFR slope for which the magnitude and direction depended on baseline eGFR.
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Affiliation(s)
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren Viborg Vestergaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Henrik Gammelager
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Birn
- Department of Clinical Medicine and Biomedicine, Aarhus University, Aarhus, Denmark,Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Dorothea Nitsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Georges TD, Marie-Patrice H, Ingrid TS, Mbua RG, Hermine FM, Gloria A. Causes and outcome of acute kidney injury amongst adults patients in two hospitals of different category in Cameroon; a 5 year retrospective comparative study. BMC Nephrol 2022; 23:364. [PMCID: PMC9661768 DOI: 10.1186/s12882-022-02992-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Acute kidney injury (AKI) is an under-recognized disorder, which is associated with a high risk for mortality, development of chronic kidney disease (CKD).
Objective
We sought to describe and compare the causes and outcomes of AKI amongst adult patients in Douala general hospital (DGH) and Buea regional hospital (BRH).
Methods
A hospital-based retrospective cohort analytic study was carried from February to April 2021. Convenience sampling was used. We included Patient’s files admitted from January 2016 to December 2020 aged > 18 years, with AKI diagnosed by a nephrologist and recorded values of serum creatinine (sCr) on admission and discharge. Data were analysed using SPSSv26. Chi-square, fisher, median mood’s and regression logistic test were used, values were considered significant at p < 0.05.
Results
Of the 349 files included 217 was from DGH and 132 from BRH. Community acquired AKI were more present in BRH 87.12% (n = 115) than DGH 84.79% (n = 184) (p = 0.001). Stage III AKI was the most common presentation in both hospital. Pre-renal AKI was more common (p = 0.013) in DGH (65.44%, n = 142) than BRH (46.97%, n = 62). Sepsis and volume depletion were more prevalent in urban area with (64.51 and 30.41% vs. 46.21 and 25.75%) while severe malaria was more present in Semi-urban area (8.33% vs. 1.84%, p = 0.011). Complete and partial renal recovery was 64.97% (n = 141) in DGH and 69.69% (n = 92) in BRH (p = 0.061). More patients had dialysis in BRH 73.07% (n = 57) than in DGH 23.33% (n = 21). More patient died in DGH 33.18% (n = 72) died than in BRH 19.70% (n = 26) (p = 0.007). Stage III was significantly associated with non-renal recovery in both DGH (p = 0.036) and BRH (p = 0.009) while acute tubular necrosis was associated with non-renal outcome in DGH (p = 0.037).
Conclusions
AKI was mainly due to sepsis, volume depletion and nephrotoxicity. Complete and partial recovery of kidney function were high in both settings. Patient outcome was poorer in DGH.
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Meraz-Muñoz AY, Jeyakumar N, Luo B, Beaubien-Souligny W, Chanchlani R, Clark EG, Harel Z, Kitchlu A, Neyra JA, Zappitelli M, Chertow GM, Garg AX, Wald R, Silver SA. Cardiovascular Drug Use After Acute Kidney Injury Among Hospitalized Patients With a History of Myocardial Infarction. Kidney Int Rep 2022; 8:294-304. [PMID: 36815105 PMCID: PMC9939314 DOI: 10.1016/j.ekir.2022.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/03/2022] [Accepted: 10/25/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Patients who survive acute kidney injury (AKI) may receive fewer cardioprotective drugs. Our objective was to measure the difference in time to dispensing of evidence-based cardiovascular drugs in patients with a history of myocardial infarction (MI) with and without AKI. Methods This was a population-based cohort study of patients 66 years of age and older with a history of MI who survived a hospitalization complicated with AKI, propensity-score matched to patients without AKI. The primary outcome was time to outpatient dispensing of an angiotensin-converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB), statin, or β-blocker within 1 year of hospital discharge. Results We identified 28,871 patients with AKI, of whom 21,452 were matched 1:1 to patients without AKI. In the matched cohort, mean age was 80 years, 40% were female, and 34% had an MI during the index hospitalization. AKI was associated with less frequent dispensing of all 3 cardiovascular drug classes within 1 year of hospital discharge (subdistribution hazard ratio [sHR], 0.93; 95% confidence interval [CI], 0.91-0.95). This association was most pronounced in patients with stage 2 (sHR, 0.81; 95% CI, 0.75-0.88) and stage 3 (sHR, 0.71; 95% CI, 0.64-0.79) AKI. We observed less frequent dispensing of statins in patients with stage 2 (sHR, 0.87; 95% CI, 0.81-0.92) and stage 3 (sHR, 0.85; 95% CI, 0.78-0.93) AKI and less frequent dispensing of β-blockers in patients with stage 3 AKI (sHR, 0.86; 95% CI, 0.79-0.94). Conclusion In patients with a history of MI, survivors of AKI were less likely to receive prescriptions for ACEi/ARB, statins, or β-blockers within 1 year of hospital discharge. This association was most pronounced in patients with stages 2 and 3 AKI.
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Affiliation(s)
| | | | - Bin Luo
- ICES, Toronto, Ontario, Canada
| | | | - Rahul Chanchlani
- ICES, Toronto, Ontario, Canada,Division of Pediatric Nephrology, McMaster Children Hospital, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada
| | - Abhijat Kitchlu
- ICES, Toronto, Ontario, Canada,Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Michael Zappitelli
- Division of Pediatric Nephrology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University, Palo Alto, California, USA
| | - Amit X. Garg
- ICES, Toronto, Ontario, Canada,Division of Nephrology, London Health Sciences Center, Western University, London, Ontario, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada
| | - Samuel A. Silver
- ICES, Toronto, Ontario, Canada,Division of Nephrology, Kingston Health Sciences Center, Queen’s University, Kingston, Ontario, Canada,Correspondence: Samuel A. Silver, Division of Nephrology, Queen’s University, 76 Stuart Street, 3-Burr 21-3-039, Kingston, Ontario K7L 2V7, Canada.
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