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Gostoli S, Raimondi G, Popa AP, Giovannini M, Benasi G, Rafanelli C. Behavioral Lifestyle Interventions for Weight Loss in Overweight or Obese Patients with Type 2 Diabetes: A Systematic Review of the Literature. Curr Obes Rep 2024:10.1007/s13679-024-00552-5. [PMID: 38436787 DOI: 10.1007/s13679-024-00552-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE OF REVIEW Around 80-90% of patients with type 2 diabetes mellitus (T2DM) are overweight or obese, presenting a greater risk for serious health complications and mortality. Thus, weight loss represents a main goal for T2DM management. Although behavioral lifestyle interventions (BLIs) could help promoting weight loss in T2DM patients with overweight or obesity, their effectiveness is still controversial. This systematic review offers an updated and comprehensive picture of BLIs according to Michie's classification in T2DM patients with overweight or obesity and identifies possible factors (related to both patients and interventions) associated with weight loss. The PRISMA guidelines were followed. The literature search till March 2023 indicated 31 studies involving 42 different BLIs. RECENT FINDINGS Our findings suggest that structured BLIs, characterized by frequent feedback and support, can lead to a clinically meaningful 5% weight loss, regardless of specific behavioral, diet, and physical activity components. Further research should address methodological issues and heterogeneity of interventions, also considering the effect of pharmacological therapies on weight reduction. Lastly, more attention should be paid to the long-term effectiveness of behavioral lifestyle interventions and to the relationship between weight loss and diabetes.
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Affiliation(s)
- Sara Gostoli
- Department of Psychology "Renzo Canestrari", University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy
| | - Giulia Raimondi
- Department of Psychology "Renzo Canestrari", University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy
| | - Alexandra Paula Popa
- Department of Psychology "Renzo Canestrari", University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy
| | - Micaela Giovannini
- Department of Psychology "Renzo Canestrari", University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy
| | - Giada Benasi
- Department of Medicine, Division of General Medicine, Columbia University Irving Medical Center, 622 West 168th Street, 10032, New York, NY, United States
| | - Chiara Rafanelli
- Department of Psychology "Renzo Canestrari", University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy.
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Curtis F, Burton JO, Butt A, Dhaliwal HK, Graham-Brown MM, Lightfoot CJ, Rawat R, Smith AC, Wilkinson TJ, March DS. Lifestyle interventions delivered by eHealth in chronic kidney disease: A scoping review. PLoS One 2024; 19:e0297107. [PMID: 38266006 PMCID: PMC10807786 DOI: 10.1371/journal.pone.0297107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
A method of overcoming barriers associated with implementing lifestyle interventions in CKD may be through the use of eHealth technologies. The aim of this review was to provide an up-to-date overview of the literature on this topic. Four bibliographical databases, two trial registers, and one database for conference proceedings were searched from inception to August 2023. Studies were eligible if they reported a lifestyle intervention using eHealth technologies. A narrative synthesis of the findings from the included studies structured around the type of eHealth intervention was presented. Where a sufficient number of studies overlapped in terms of the type of intervention and outcome measure these were brought together in a direction of effect plot. There were 54 included articles, of which 23 were randomised controlled trials (RCTs). The main component of the intervention for the included studies was mobile applications (n = 23), with the majority being in the dialysis population (n = 22). The majority of eHealth interventions were reported to be feasible and acceptable to participants. However, there was limited evidence that they were efficacious in improving clinical outcomes with the exception of blood pressure, intradialytic weight gain, potassium, and sodium. Although eHealth interventions appear acceptable and feasible to participants, there is insufficient evidence to make recommendations for specific interventions to be implemented into clinical care. Properly powered RCTs which not only demonstrate efficacy, but also address barriers to implementation are needed to enhance widespread adoption.
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Affiliation(s)
- Ffion Curtis
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, United Kingdom
| | - James O. Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ayesha Butt
- Leicester Diabetes Centre, University of Leicester, Leicester, United Kingdom
| | | | - Matthew M.P. Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Courtney J. Lightfoot
- Department of Population Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Rishika Rawat
- Leicester Medical School, University of Leicester, Leicester, United Kingdom
| | - Alice C. Smith
- Department of Population Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Thomas J. Wilkinson
- Leicester Diabetes Centre, University of Leicester, Leicester, United Kingdom
| | - Daniel S. March
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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Hui M, Zhang D, Ye L, Lv J, Yang L. Digital Health Interventions for Quality Improvements in Chronic Kidney Disease Primary Care: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2024; 13:364. [PMID: 38256498 PMCID: PMC10816029 DOI: 10.3390/jcm13020364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/10/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a significant public health issue globally. The importance of its timely identification and early intervention is paramount. However, a systematic approach for early CKD management in the primary care setting is currently lacking, receiving less attention compared to upstream risk factors such as diabetes and hypertension. This oversight may lead to a failure in meeting quality-of-care indicators. Digital health interventions (DHIs), which leverage digital tools to enhance healthcare delivery, have shown effectiveness in managing chronic diseases and improving the quality, safety, and efficiency of primary care. Our research aimed to evaluate the effectiveness of DHIs in the care process, focusing on their reach, uptake, and feasibility. METHODS In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov for randomized controlled trials (RCTs) assessing DHIs' effectiveness in CKD patient care among adults in primary care settings. The search, conducted on 30 June 2023, included studies published in English from 1 January 2009. Screening was conducted using Covidence, adhering to Cochrane's guidelines for data extraction. We primarily evaluated changes in care processes (testing, documentation, medication use, etc.) and the use of renin-angiotensin-aldosterone system inhibitors (RAASi), referrals, among others. Multilevel meta-analysis was employed to address within-study clustering, and meta-regression analyzed the impact of study characteristics on heterogeneity in effect sizes. Clinical endpoints were recorded where available. Bias risk was assessed using the Cochrane Risk of Bias 2 tool. Data on reach, uptake, and feasibility were narratively summarized. The study is registered with PROSPERO (CRD42023449098). RESULTS From 679 records, 12 RCTs were included in the narrative synthesis, and 6 studies (encompassing 7 trials) in the meta-analysis. The trials indicated a -0.85% change (95%CI, -5.82% to 4.11%) in the proportion of patients receiving desired care. This result showed considerable heterogeneity (I2 = 91.9%). One study characteristic (co-intervention, education) correlated with larger effects. Although including co-intervention in multivariable meta-regression was significant, it did not diminish heterogeneity. The reported reach varied and was not high, while the uptake was relatively high. Most studies did not explicitly address feasibility, though some statements implied its evaluation. CONCLUSIONS The current literature on the impact of DHIs in community-based CKD care is limited. The studies suggest a non-significant effect of DHIs on enhancing CKD management in community settings, marked by significant heterogeneity. Future research should focus on rigorous, methodologically sound implementations to better assess the effectiveness of DHIs in the primary care management of CKD.
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Affiliation(s)
- Miao Hui
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China (J.L.); (L.Y.)
- Department of Cell Biology and Stem Cell Research Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing 100191, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China
| | - Duoduo Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China (J.L.); (L.Y.)
- Department of Cell Biology and Stem Cell Research Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing 100191, China
| | - Lili Ye
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China (J.L.); (L.Y.)
- Department of Cell Biology and Stem Cell Research Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing 100191, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China (J.L.); (L.Y.)
- Department of Cell Biology and Stem Cell Research Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing 100191, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China (J.L.); (L.Y.)
- Department of Cell Biology and Stem Cell Research Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing 100191, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China
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Biruete A, Hill Gallant KM, Lloyd L, Meade A, Moe SM, St-Jules DE, Kistler BM. 'Phos'tering a Clear Message: The Evolution of Dietary Phosphorus Management in Chronic Kidney Disease. J Ren Nutr 2023; 33:S13-S20. [PMID: 37343779 PMCID: PMC10728341 DOI: 10.1053/j.jrn.2023.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 04/21/2023] [Accepted: 05/04/2023] [Indexed: 06/23/2023] Open
Abstract
Phosphorus is a vital nutrient, but disturbances in phosphorus homeostasis are central to chronic kidney disease-mineral and bone disorder. To minimize disturbances, traditional dietary guidance focused on a numerical phosphorus target leading to the exclusion of many healthy foods and implementation challenges. Contemporary phosphorus guidance focuses on dietary source, avoiding additives, and emphasizing low-phosphorus bioaccessibility foods, leading to a more liberal approach. Additional work is needed to demonstrate the efficacy of these contemporary approaches and understand the influence of specific foods, processing, and cooking methods. Unfortunately, patient education using traditional and contemporary strategies may give mixed messages, particularly related to plant-based foods. Thus, greater clarity on the effects of specific foods and dietary patterns may improve phosphorus education. This review aims to discuss the evolution of dietary phosphorus management while highlighting areas for future research that can help move the field toward stronger evidence-based guidance to prevent and treat hyperphosphatemia.
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Affiliation(s)
- Annabel Biruete
- Department of Nutrition and Dietetics, Indiana University-Purdue University Indianapolis, Indianapolis; Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis; Department of Nutrition Science, Purdue University, West Lafayette, Indiana
| | - Kathleen M Hill Gallant
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis; Department of Food Science and Nutrition, University of Minnesota, St. Paul
| | - Lyn Lloyd
- Nutrition and Dietetics, Auckland City Hospital, Auckland, New Zealand
| | - Anthony Meade
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Sharon M Moe
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis
| | | | - Brandon M Kistler
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana; Department of Nutrition and Health Science, Ball State University, Muncie.
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Geurts KAM, Woodcock-Nekeman S, Hummel M, Dietvorst CAW, van Rossum EFC, Berk KA. The Effect of Including eHealth in Dietary Interventions for Patients with Type 2 Diabetes with Overweight or Obesity: A Systematic Review. Nutrients 2023; 15:3776. [PMID: 37686808 PMCID: PMC10490324 DOI: 10.3390/nu15173776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
eHealth has a growing impact on the delivery of healthcare, making health systems more efficient. This study examined the effect of dietary interventions using eHealth compared to face-to-face contact in patients with (pre-) type 2 diabetes (T2D) and who are overweight/obese. Literature databases were searched upon November 2022. Inclusion criteria: randomized controlled trial; duration ≥ 6 months; involving dietary interventions; performed in adults with (pre-) T2D and who are overweight/obese; using eHealth compared to face-to-face contact; and report outcomes on weight loss, glycemic regulation, and/or cost-effectiveness. Selection of articles was performed manually and using ASReviewLab. Fifteen studies were included for data extraction, investigating a wide variety of eHealth interventions. Seven studies reporting on weight loss showed a significant between-group difference (-1.18 to -5.5 kg); five studies showed a trend in favor of the eHealth programs. Eleven studies reported on HbA1c; three found a significant between-group difference (-0.23 to -0.70%) in favor of the eHealth programs and six studies showed non-significant improvements. Interaction with healthcare professionals led to better results of the dietary interventions. Two studies reported incomplete data on cost-effectiveness. In conclusion, eHealth shows better results of dietary interventions in (pre-) T2D patients compared to face-to-face, especially when combined with interaction with healthcare professionals.
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Affiliation(s)
- Karlijn A. M. Geurts
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (K.A.M.G.); (S.W.-N.); (C.A.W.D.)
| | - Sandra Woodcock-Nekeman
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (K.A.M.G.); (S.W.-N.); (C.A.W.D.)
| | - Mitchell Hummel
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (K.A.M.G.); (S.W.-N.); (C.A.W.D.)
| | - Carmen A. W. Dietvorst
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (K.A.M.G.); (S.W.-N.); (C.A.W.D.)
| | - Elisabeth F. C. van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands;
- Obesity Center CGG, Erasmus MC, University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Kirsten A. Berk
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, University Medical Centre Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (K.A.M.G.); (S.W.-N.); (C.A.W.D.)
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Neale EP, Rosario VD, Probst Y, Beck E, Tran TB, Lambert K. Lifestyle Interventions, Kidney Disease Progression, and Quality of Life: A Systematic Review and Meta-analysis. Kidney Med 2023; 5:100643. [PMID: 37235039 PMCID: PMC10205767 DOI: 10.1016/j.xkme.2023.100643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Rationale & Objective Poor dietary patterns and low physical activity levels are important lifestyle-related factors that contribute to negative health outcomes in individuals with chronic kidney disease (CKD). Previous systematic reviews have not explicitly focused on these lifestyle factors, nor undertaken meta-analyses of any effects. We aimed to evaluate the effect of lifestyle interventions (such as diet, exercise, and other lifestyle-related interventions) on the risk factors for and progression of CKD and the quality of life. Study Design Systematic review and meta-analysis. Setting & Study Populations Individuals aged 16 years or older with CKD stages 1 to 5 not requiring kidney replacement therapy. Selection Criteria for Studies Randomized controlled trials of interventions. Data Extraction Kidney function, albuminuria, creatinine, systolic blood pressure, diastolic blood pressure, body weight, glucose control, and quality of life. Analytical Approach A random-effects meta-analysis with evidence certainty assessed using GRADE. Results Seventy-eight records describing 68 studies were included. Twenty-four studies (35%) were dietary interventions, 23 (34%) exercise, 9 (13%) behavioral, 1 (2%) hydration, and 11 (16%) multiple component. Lifestyle interventions resulted in significant improvements in creatinine (weighted mean difference [WMD], -0.43 mg/dL; 95% CI, -0.74 to -0.11; P = 0.008); 24-hour albuminuria (WMD, -53 mg/24 h; 95% CI, -56 to -50; P < 0.001); systolic blood pressure (WMD, -4.5 mm Hg; 95% CI, -6.7 to -2.4; P < 0.001); diastolic blood pressure (WMD, -2.2 mm Hg; 95% CI, -3.7 to -0.8; P = 0.003); and body weight (WMD, -1.1 kg; 95% CI, -2.0 to -0.1; P = 0.025). Lifestyle interventions did not result in significant changes in the estimated glomerular filtration rate (0.9 mL/min/1.73 m2; 95% CI, -0.6 to 2.3; P = 0.251). However, narrative synthesis indicated that lifestyle intervention resulted in improvements in the quality of life. Limitations Certainty of the evidence was rated very low for most outcomes, primarily owing to the risk of bias and inconsistency. No meta-analysis was possible for quality-of-life outcomes because of variations in measurement tools. Conclusions Lifestyle interventions seem to positively affect some risk factors for progression of CKD and quality of life.
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Affiliation(s)
| | | | | | | | | | - Kelly Lambert
- Address for Correspondence: Kelly Lambert, PhD, School of Medical, Indigenous and Health Science, University of Wollongong, Northfields Ave, Wollongong, NSW, 2522, Australia.
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Khor BH, Sumida K, Scholes-Robertson N, Chan M, Lambert K, Kramer H, Lui SF, Wang AYM. Nutrition Education Models for Patients With Chronic Kidney Disease. Semin Nephrol 2023; 43:151404. [PMID: 37598539 DOI: 10.1016/j.semnephrol.2023.151404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Nutrition is an integral component in the management of chronic kidney disease (CKD), and kidney health professionals play a crucial role in educating patients on dietary interventions for CKD. Several dietary modifications are indicated for CKD that require frequent adaptations with CKD progression and with underlying metabolic disturbances. However, poor adherence to dietary interventions is not uncommon among patients with CKD. An effective education program on nutrition intervention consists of providing knowledge and developing skills that are necessary to support behavioral change. The application of theoretical models of behavioral change such as social cognitive theory and the transtheoretical model in nutrition intervention has been reported to be effective in promoting changes in dietary habits. This review summarizes the evidence supporting the application of theoretical models as strategies to enhance nutrition education for patients with CKD. In addition, digital technologies are gaining interest in empowering patients and facilitating nutrition management in patients with CKD. This review also examines the applications of the latest digital technologies guided by behavioral theory in facilitating patients' changes in dietary intake patterns and lifestyle habits.
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Affiliation(s)
- Ban-Hock Khor
- Faculty of Food Science and Nutrition, University Malaysia Sabah, Sabah, Malaysia.
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Maria Chan
- Department of Nutrition and Dietetics, The St. George Hospital, Kogarah, New South Wales, Australia
| | - Kelly Lambert
- School of Medicine, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Holly Kramer
- Departments of Public Health Sciences and Medicine, Loyola University, Chicago, IL, USA
| | - Siu-Fai Lui
- Hong Kong Kidney Foundation, Hong Kong, China
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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Boaz M, Kaufman-Shriqui V, Moore LW, Kalantar-Zadeh K. Diet Quality Index in Kidney Health and Kidney Disease. J Ren Nutr 2023; 33:1-3. [PMID: 36526157 DOI: 10.1053/j.jrn.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Mona Boaz
- Department of Nutrition Sciences, School of Health Sciences, Ariel University, Ariel, Israel.
| | - Vered Kaufman-Shriqui
- Department of Nutrition Sciences, School of Health Sciences, Ariel University, Ariel, Israel
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Transplantation, Department of Medicine, University of California-Irvine, Irvine, California
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