The Results of Continual Dialysis on Bodily Standing, High quality of Life, and Arterial Stiffness: A Longitudinal Examine in Prevalent Dialysis Sufferers – FullText – Nephron 2021, Vol. 145, No. 1
Introduction: It’s broadly recognized that dialysis sufferers have considerably impaired useful outcomes and arterial stiffness, however nonetheless few research have investigated the consequences of dialysis longitudinally by a multidimensional method. We aimed to evaluate longitudinal patterns of bodily exercise (PA), bodily functioning (PF), health-related high quality of life (HrQoL), physique composition (BC), and arterial stiffness in prevalent dialysis sufferers. Supplies and Strategies: Thirty-nine prevalent dialysis sufferers (23 standard hemodialysis [CHD] and 16 peritoneal dialysis) with a imply classic of 25.7 (±22.1) months have been included on this observational potential research with a 2-year follow-up, and at baseline 20 wholesome controls have been included. Measurements have been carried out each 6 months. HrQoL was assessed utilizing the Brief Type-36 (SF-36) questionnaire. PA was assessed utilizing the SenseWear™ Pro3 accelerometer. PF was assessed by strolling velocity, the PF subscale of the SF-36, and handgrip energy (HGS). BC was assessed utilizing the Physique Composition Monitor® and arterial stiffness by measuring carotid-femoral pulse wave velocity (PWV). The longitudinal pattern was assessed utilizing linear blended fashions, correcting for intercourse, age, and dialysis classic. For PWV, the pattern was moreover corrected for diabetes and systolic blood strain. Outcomes: After correction, no statistically vital adjustments over time have been noticed for the parameters of PA, PF, HrQoL, and BC. Within the mixed group and within the group of CHD sufferers solely, a major change was noticed for PWV (total pattern: p = 0.007 and p = 0.008, respectively). A statistically vital distinction at baseline was noticed between dialysis sufferers and wholesome controls in all parameters, aside from HGS and PWV. Dialogue/Conclusion: We noticed no statistically vital adjustments in useful outcomes throughout a 2-year follow-up interval, however a major enhance was noticed for arterial stiffness. These outcomes may counsel that after a sure interval in time, a comparatively steady course is current in useful outcomes, however an ongoing deterioration in arterial stiffness happens, which could enhance the danger of heart problems and all-cause mortality in these sufferers.
© 2020 The Creator(s)Revealed by S. Karger AG, Basel
The variety of incident dialysis sufferers will increase every year, for example, because of the rising proportion of aged sufferers and improved dialysis methods , and it’s estimated that these numbers will proceed to rise every year with roughly 6% . Though health-related high quality of life (HrQoL) has total improved in dialysis sufferers within the final many years , it’s broadly recognized that this affected person group nonetheless has diminished HrQoL, decrease ranges of bodily exercise (PA), and decreased bodily functioning (PF), as in contrast with the final inhabitants [4, 5]. Furthermore, a decline in HrQoL and PA is related to an elevated threat of mortality and hospitalization [6, 7]. Due to this fact, it is very important monitor and appropriately establish these parameters on this affected person group. Particularly since sufferers with end-stage renal illness (ESRD) have a ten–20 instances greater threat of dying as a result of heart problems (CVD) as in contrast with the final inhabitants .
Regardless of these potential modifiable parameters, research have proven that self-management applications and stimulation of PA by nephrologists and dialysis workers stay underexposed [6, 9, 10] and are usually not gaining extra reputation over time [11-13]. It’s well known that in dialysis sufferers, opposed outcomes are usually not solely related to one single threat issue. Due to this fact, a multidimensional evaluation of dialysis sufferers utilizing easy and noninvasive exams reminiscent of measuring handgrip energy (HGS), strolling velocity (WS), administering of Brief Type-36 (SF-36) questionnaires, physique composition (BC) measurements, and measurement of pulse wave velocity (PWV), to find out arterial stiffness, might contribute to raised insights of mortality threat, threat of hospitalization, and CVD threat on this affected person group.
As well as, early detection of adjustments in these parameters might information clinicians to optimize therapy and inspire sufferers to take part in train applications, thereby optimizing HrQoL and presumably lower their threat of mortality and hospitalization. A number of research have investigated adjustments in PA, PF, HrQoL, BC, and PWV in dialysis sufferers handled with totally different dialysis modalities [14-17]. Nevertheless, to one of the best of our data, these research didn’t mix the parameters and have been typically cross-sectional in nature.
On this longitudinal potential research, it’s hypothesized that continual dialysis, when carried out over extended durations of time, results in additional deterioration of PA, PF, HrQoL, alterations in BC, and arterial stiffness. The goals of this research have been to evaluate (1) patterns of change in parameters of PA, PF, HrQoL, BC, and arterial stiffness in prevalent continual dialysis sufferers throughout a 2-year follow-up and (2) doable correlations between these parameters.
Supplies and Strategies
This research included contributors from 2 separate observational research. The measurements as described beneath have been mentioned beforehand by our group [17-21].
Sufferers have been included from a research which was carried out between June 2012 and December 2017. Knowledge from 39 prevalent dialysis sufferers that have been recruited within the research “Uremic Toxins, Cardiovascular Impact, and Bodily Exercise in Intensive Hemodialysis (INTHEMO),” have been included within the analyses. In these analyses, solely knowledge from standard hemodialysis (CHD) and peritoneal dialysis (PD) sufferers have been used. Outcomes of the intensive hemodialysis group have been beforehand revealed [20, 22] and have been subsequently excluded for the analyses. At baseline, 20 wholesome age- and sex-matched controls have been included as a management group, who have been included from a research which was carried out between February 2012 and July 2017.
Sufferers have been eligible for inclusion in the event that they have been incident or prevalent hemodialysis or PD sufferers, 18 years of age or older, and in a position to present knowledgeable consent. Sufferers who had strict medical indication for CHD (≤12-h hemodialysis per week), anticipating renal transplantation or switching dialysis modality inside 12 months, had a Charlson Comorbidity Index of 5 or greater, had a colectomy or used antibiotics chronically, or had a pacemaker or implantable cardioverter defibrillator have been excluded from participation.
Workplace blood strain was measured with an digital sphygmomanometer (Omron M4-I; Omron, Japan). Knowledge have been collected by skilled researchers earlier than every sufferers’ midweek dialysis over a follow-up interval of two years, with every knowledge assortment go to roughly 6 months aside, yielding a complete of 5 visits.
PA was measured as whole steps taken per 24h, whole power expenditure (kcal/kg/day), and activity-related power expenditure (kcal/kg/day). Individuals have been requested to put on a SenseWearTM Pro3 armband (BodyMedia®, Pittsburgh, PA, USA) for two consecutive days. There was no distinction made between measurements of weekdays and weekends. The imply of the full on-body time was calculated to compromise each dialysis and nondialysis days. The SenseWearTM armband has been validated for acquiring satisfactory knowledge on every day PA [23, 24].
The parameters that have been outlined inside PF have been WS, HGS, and the PF subscale of the SF-36 (SF-36 PF) questionnaire.
4-Meter Strolling Take a look at
The 4-m strolling take a look at was used to evaluate WS (meters per second). The validity and sensitivity of this take a look at have been confirmed by a number of research [25-28] and have been additionally confirmed to be used in PF in ESRD sufferers .
Muscle energy, as a parameter of PF, was assessed by figuring out HGS (in kilograms [kg]) with a handheld dynamometer (Jamar®; Sammons Preston Inc., Bolingbrook, IL, USA). Evaluation of HGS was carried out in a standing place with the arm in a flexed place of 90°, contralateral to the shunt arm (CHD sufferers) or in PD sufferers within the dominant hand. This process was carried out twice throughout every go to, and the imply of each measurements was used for evaluation.
Well being-Associated High quality of Life
The broadly used SF-36 survey was used to evaluate HrQoL scores. The SF-36 is validated to be used in ESRD sufferers [30, 31] and consists of 36 objects with scores starting from zero (worst doable well being) to 100 (absolute best well being). This stuff may be transformed into 8 subscales (PF, role-physical, bodily ache, normal well being, vitality, social functioning, position emotional, and psychological well being). The subscales may be transformed right into a bodily element abstract (PCS) rating and a psychological element abstract (MCS) rating. Questionnaires have been scored utilizing the algorithm by Ware et al. [32, 33]. To normalize scores, t-score transformation was used to make them corresponding to the final inhabitants and different sufferers with particular ailments . Self-reported PF was measured utilizing the PF subscale of the SF-36. PA-related high quality of life was outlined utilizing the PCS rating from the SF-36.
Bioimpedance spectroscopy was used to evaluate BC. This was achieved with the Physique Composition Monitor (BCM®; Fresenius Medical Care, Dangerous Homburg, Germany), which makes use of a 3-compartment mannequin through which adipose tissue mass, lean tissue mass, and a separate fluid overload (FO) compartment may be decided . Lean tissue index (LTI) and fats tissue index (FTI) are calculated as lean tissue mass and adipose tissue mass, respectively, corrected for peak.
PD sufferers have been visited within the outpatient clinic. For sensible causes, PD sufferers have been measured with a full stomach. Moreover, sequestered fluid within the trunk has solely a minor affect on whole-body bioimpedance measurements [36-38]. Per producers’ directions, physique weight was corrected for PD fluid, and measurements have been carried out with contributors mendacity in mattress or sitting reclined in a dialysis chair previous to the dialysis therapy .
Pulse Wave Velocity
As a parameter of arterial stiffness, PWV was assessed. Elevated arterial stiffness as measured by PWV is taken into account to be an unbiased predictor for all-cause mortality and CVD in ESRD sufferers . PWV was assessed with the SphygmoCor system (AtCor Medical, Sydney, Australia) utilizing applanation tonometry by the use of the carotid and femoral artery.
Laboratory parameters reminiscent of dialysis adequacy (Kt/V), β2-microglobulin, and routine laboratory measurements have been decided throughout routine affected person laboratory measurements.
Dialysis Remedy Modalities
Detailed knowledge on renal alternative remedy modalities have been collected retrospectively and might be retrieved for 20 CHD sufferers and 16 PD sufferers. In prevalent CHD sufferers, dialysis was carried out 3 instances per week for about 4 h, utilizing ultrapure dialysates and largely high-flux dialyzers with artificial membranes. As well as, 4 CHD sufferers have been on low-flux dialyzers with artificial membranes. 4 sufferers have been handled with hemodiafiltration. Vascular entry was by way of an arteriovenous shunt in all CHD sufferers.
Twenty-two CHD sufferers have been prescribed a dialysate with 1.50 mmol/L calcium, and 1 CHD affected person was prescribed a dialysate with 1.25 mmol/L calcium. In PD sufferers, a calcium focus of 1.25 mmol/L was used.
In PD sufferers, solely PD fluids with low glucose-derived degradation product content material have been used (Physioneal®, Extraneal®, and Nutrineal® from Baxter, Castlebar, Eire). The glucose focus was prescribed on the discretion of the treating doctor.
Different Scientific Traits
Electronical medical information from contributors have been used to retrieve knowledge reminiscent of renal analysis, dialysis classic, comorbidity (diabetes, hypertension, weight problems, and cardiovascular historical past), and drugs use. These have been utilized to retrospectively derive the Davies’s comorbidity rating  that divides contributors into 3 mortality threat teams: low, medium, and excessive. The Davies comorbidity rating has been validated in ESRD sufferers  and considerably correlates with hospitalization and mortality [41, 43].
Numerical knowledge are offered as imply ± SD and categorical knowledge as % or median (twenty fifth–seventy fifth percentile). Evaluation at baseline, between dialysis sufferers and wholesome controls, was assessed utilizing the independent-samples t exams or Mann-Whitney U exams, as acceptable. The longitudinal pattern over time (0, 6, 12, 18, and 24 months) was assessed utilizing linear blended mannequin evaluation to include all out there knowledge and account for correlation between repeated measurements inside the similar affected person. A number of covariance buildings for repeated measures have been thought of, reminiscent of unstructured, autoregressive transferring common (1,1), (heterogeneous) first-order autoregressive, and (heterogenous) compound symmetric, the place one of the best becoming in accordance with the Bayesian info criterion was chosen and reported, with time as a categorical fastened impact and no random results. All time traits have been adjusted for age, intercourse, and dialysis classic. For PWV, outcomes have been moreover adjusted for diabetes and systolic blood strain as is frequent for this parameter. As well as, variables associated to lacking end result values have been included as a set impact to fulfill the belief of lacking at random. As subgroup evaluation, traits over time inside the CHD group have been analyzed for these parameters which turned out to be vital within the mixed group. For the PD group, solely descriptive statistics, that’s, noticed means ± SD per time level, have been computed because the variety of sufferers inside this group was restricted.
Correlations between baseline values and between change scores (24 months vs. baseline) of PA, PF, HrQoL, BC, and PWV have been assessed with Pearson’s correlation coefficient or Spearman’s rho, the place acceptable. Statistical analyses have been carried out utilizing IBM SPSS Statistics for Mac model 24 (IBM Corp., Armonk, NY, USA). Two-sided p values ≤0.05 have been thought of to be statistically vital.
In whole, 39 sufferers (23 CHD and 16 PD) from 1 middle have been included. The imply (±SD) age was 62.5 ± 13.2 years, and 74.4% have been male. Baseline traits are offered in Desk 1. Throughout follow-up, a complete of 11 (28.2%) contributors underwent a kidney transplant, 2 (5.1%) contributors died, 1 (2.6%) participant was excluded as a result of malignancy, and 1 (2.6%) participant was excluded as a result of cessation of dialysis. Between PD and CHD sufferers, no statistically vital variations in residual kidney perform in accordance with CKD-EPI have been noticed at baseline (p = 0.288).
At baseline, statistically vital variations have been noticed in all parameters between dialysis sufferers and wholesome controls, aside from PWV and HGS. A pattern towards significance was noticed with HGS. Outcomes are offered in Desk 2.
The longitudinal findings for indicators of dialysis effectivity are reported in on-line suppl. Desk 1 (see www.karger.com/doi/10.1159/000510624 for all on-line suppl. materials). For PA measurements, imply on physique time for the SenseWearTM Pro3 armband was >95% for all visits. The typical monitoring interval in days was 2.18 ± 0.70, 1.97 ± 0.23, 1.81 ± 0.29, 1.81 ± 0.37, and 1.73 ± 0.34 for visits 1–5, respectively.
Throughout 2-year follow-up, no vital adjustments have been noticed in parameters of PA, that’s, the variety of steps, whole power expenditure, and activity-related power expenditure (total p values ≥0.387, Desk 3). For each objectively measured PF via WS and HGS and subjectively measured PF by SF-36 PF, no vital adjustments have been noticed over time (total p values ≥0.292, Desk 4).
Concomitant, for HrQoL parameters, no vital longitudinal adjustments have been noticed within the abstract scores of the SF-36, that’s, PCS (total p = 0.236) and MCS (total p = 0.587, Desk 3). With regard to BC parameters, LTI, FTI, and FO didn’t change considerably over time (total p values ≥0.351, Desk 5). Nonetheless, our research confirmed that 60.7% of the male sufferers and 30.0% of the feminine sufferers had an LTI beneath the tenth percentile.
Nevertheless, for PWV, a major enhance was noticed throughout the 2-year follow-up interval. A rise in PWV was noticed from 11.93 m/s (95% CI: 10.56–13.30) at baseline to 14.41 m/s (95% CI: 12.90–15.93) after 24 months of follow-up (Desk 6; Fig. 1). In a further evaluation inside CHD sufferers solely, PWV considerably elevated from 12.31 m/s (95% CI: 10.85–13.78) at baseline to fifteen.34 m/s (95% CI: 13.68–17.00) after 24 months of follow-up (total p = 0.008), adjusting for age, intercourse, and systolic blood strain.
Examination of the group of PD sufferers individually (n = 9, after 24 months) confirmed elevated ranges of PWV from 11.71 m/s (±4.35) at baseline to 13.92 m/s (±4.17) after 24 months of follow-up. Nevertheless, as a result of small pattern dimension, no statistical evaluation was carried out.
Correlations between PA, PF, HrQoL, PWV, and BC
Determine 2 reveals that vital correlations have been noticed at baseline for SF-36 PF with objectively measured parameters of PF and PA: HGS (r = 0.394, p = 0.014), variety of steps (r = 0.380, p = 0.019), and WS (r = 0.458, p = 0.004). Moreover, variety of steps correlated considerably with WS (r = 0.523, p = 0.001), and HGS correlated considerably with LTI (r = 0.654. p < 0.001).
Correlations in change scores have been noticed for WS with PCS (rs = −0.498, p = 0.016) and FTI with PCS and SF-36 PF scores (rs = −0.550, p = 0.007 and rs = −0.420, p = 0.046, respectively). For PWV, correlations have been discovered with PCS (rs = −0.441, p = 0.031) and HGS (rs = −0.459, p = 0.028). No correlation was noticed between PWV and FO. Additionally, no correlations between SF-36 PF and LTI have been noticed.
The present research targeted on longitudinal patterns in varied domains in prevalent dialysis sufferers, over a 2-year follow-up interval. No statistically vital adjustments have been noticed within the studied parameters of PA, PF, HrQoL, and BC. Nevertheless, a statistically vital enhance in PWV was noticed within the total group and the subgroup of CHD sufferers.
At baseline, a statistically vital distinction between CHD sufferers and heathy controls was noticed for all parameters, aside from HGS and PWV. That is in keeping with earlier findings the place it’s broadly recognized that dialysis sufferers have diminished HrQoL, decrease ranges of PA, and decreased PF, as in contrast with the final inhabitants [4, 5].
Whereas dialysis is an intensive therapy with typically restrictions in eating regimen and fluid consumption, dialysis sufferers have a substantial greater threat of cardiovascular occasions than nondialysis sufferers and infrequently have concomitant extreme limitations in actions of every day dwelling. These findings may counsel that, in steady continual dialysis sufferers, no additional deterioration in parameters of bodily standing, HrQoL, or BC essentially happen past the already considerably decreased ranges that are already current in the beginning of dialysis. Furthermore, in a earlier longitudinal research of our group , no vital adjustments have been noticed in parameters of HrQoL in a bunch of CKD-5 nondialysis sufferers within the first yr after the transition interval from CKD-5 nondialysis to dialysis. Moreover, no vital adjustments in PA within the first 6 months after initiation of dialysis have been noticed in that research as effectively .
The findings within the present research are partially in keeping with an earlier research by Johansen et al. , the place no vital adjustments in PF, measured by SF-36, have been noticed. Nevertheless, in distinction to our findings, there was a major change in PA measured by accelerometry, which might presumably be defined by variations in baseline traits between our research and the research by Johansen et al.  reminiscent of imply age, intercourse (ratio males to females), and variations in measurement items (variety of steps in our research vs. arbitrary items).
Moreover, with regard to parameters of HrQoL, our outcomes confirmed no vital adjustments over time within the abstract scores of the SF-36 (MCS and PCS), which is in keeping with the research by Johansen et al. , the place HD sufferers who had a 1-year follow-up confirmed no vital adjustments in numerous domains of the SF-36 (MCS, PCS, and PF), and a research by Eneanya et al. , through which no vital adjustments over time within the MCS and PCS domains in a bunch of HD and PD sufferers have been noticed.
From the outcomes of the current research, along with these of earlier research, it may be hypothesized that deterioration with regard to PA, PF, and HrQoL may already happen in earlier levels of CKD, and solely minor adjustments happen throughout the dialysis course of in outcomes of useful parameters in comparatively steady sufferers.
Additionally, no vital adjustments over time have been noticed within the BC area, as expressed by FTI, LTI, and FO, throughout follow-up. This may be defined by the steady illness setting as effectively, together with periodic dietician session.
Our outcomes are in some distinction to a latest research by Marcelli et al. , through which vital adjustments in each LTI and FTI have been discovered throughout a 2-year follow-up interval in incident dialysis sufferers, the place LTI decreased and FTI elevated. Nevertheless, in our research, the imply dialysis classic was 25.7 months. This may counsel that after a finite interval, a steady illness course is reached with regard to BC parameters. Nonetheless, our research confirmed that a big a part of the sufferers had LTI beneath the tenth percentile, as was additionally noticed within the research by Marcelli et al. . This may be an indication of protein power losing, which is thought to be an necessary threat think about dialysis sufferers for survival and cardiovascular threat [46, 47]. That is in all probability a part of the frail phenotype which is repeatedly noticed in dialysis sufferers  however ought to be thought of as speculation producing solely.
In distinction to the opposite dimensions, a change was noticed for PWV, as a parameter of arterial stiffness, in each the general group and inside the subgroup of CHD sufferers, whereas in PD sufferers, a numerical pattern may be noticed. Nevertheless, no statistical evaluation might be carried out because of the small variety of PD sufferers within the present research. That is in keeping with a earlier research by Blacher et al.  that noticed a major enhance in PWV over time in a bunch of CHD sufferers. The rise might be defined by ongoing injury of uremic toxins, abnormalities in mineral metabolism, low-grade irritation from dialyzers, and FO [49, 50]. These components, related to ESRD, contribute to an setting which results in arterial transforming and calcification . As well as, PWV is thought to be an unbiased predictor for all-cause mortality and CVD in sufferers with ESRD [40, 51].
Moreover, on this research, correlations have been assessed between the totally different dimensions. The correlations inside the PF area and between the domains of PA and PF are in keeping with earlier research correlating PA parameters to outcomes within the bodily domains of HrQoL [19, 52]. These outcomes are explainable since each PF and PA contribute to the general bodily standing of sufferers.
Furthermore, correlations for change scores in PWV correlated inversely with these in PCS and HGS. No vital correlations have been discovered with FO.
Between the domains of BC and PF, longitudinal adjustments in FTI inversely correlated with these in SF-36 PF. A constructive correlation at baseline was discovered between LTI and HGS. Correlations between BC and PF have been additionally noticed in a research by Martinson et al.  the place correlations between BC and PF have been noticed in HD sufferers though different parameters have been used. Furthermore, the noticed correlation between LTI and HGS at baseline is in keeping with a cross-sectional research by Garagarza et al.  in HD sufferers . The correlations between BC and PF may be defined by the truth that the assessed parameters of PF are partly depending on lean tissue reminiscent of in WS and HGS .
Few limitations deserve consideration within the present research. First to be thought of is the comparatively small research inhabitants in distinction to earlier follow-up research. Nonetheless, we imagine this research is comparatively distinctive in offering a longitudinal multidimensional method whereby each related threat components in addition to necessary components affecting HrQoL of the sufferers have been included. We acknowledge that the dearth of statistically vital adjustments in all dimensions, besides from arterial stiffness, may be as a result of choice bias, as more healthy, extra steady dialysis sufferers have been included as compared with the final dialysis inhabitants.
Second, PA was measured for a comparatively brief time frame with no differentiation made between weekdays and weekends, which might result in over- or underestimation of the separate PA parameters. Nonetheless, though measured for a comparatively brief interval, earlier research confirmed that that is thought of adequate to assemble dependable knowledge [23, 24]. Because of the measuring methods used on this current research, we have been in a position to receive each subjectively measured and objectively measured knowledge for PF.
Third, this research consisted of each PD and CHD sufferers. Since PD sufferers are typically thought of to be in higher well being than CHD sufferers, this might have led to bias and problem in extrapolation of the outcomes to particular dialysis modalities as a result of small pattern sizes in each teams.
We discovered no vital adjustments over a 2-year follow-up interval in dialysis sufferers with regard to parameters of PA, PF, HrQoL, and BC. These outcomes along with the outcomes of earlier research may counsel that a big a part of the deterioration of useful outcomes presumably happens in earlier levels of CKD. Moreover, it may be prompt that after a sure interval in time, a steady illness course may be reached with regard to useful outcomes in dialysis sufferers who’re in comparatively good well being. Nonetheless, a progressive enhance in arterial stiffness was noticed inside continued dialysis sufferers, which could enhance the danger of CVD and all-cause mortality on this affected person group. These outcomes may help clinicians in decoding adjustments within the totally different threat domains, as our research means that even extended dialysis therapy doesn’t essentially result in an additional deterioration of the studied parameters.
The authors kindly acknowledge drs. Nanda M.P. Diederen for her contribution to the info acquisition.
Assertion of Ethics
Written knowledgeable consent was obtained for every participant. Approval of the research was given by the moral committee (NL35039.068.10 [patient group] and NL33129.068.10 [healthy controls]) and by the hospital board of the collaborating middle, Maastricht College Medical Middle+ (MUMC+).
Battle of Curiosity Assertion
N.J.H.B. and J.P.Ok. acquired lectures charges from Fresenius Medical Care. R.J.R.G., T.C., F.M.v.d.S., and B.J.W. haven’t any conflicts of curiosity to declare.
This research was supported by a Baxter Worldwide extramural grant (grant reference quantity 11CECHHDEU1004) and the Dutch Kidney Basis (grant reference quantity SB166) (affected person group) and a restricted grant from Fresenius Medical Care Europe (wholesome management group).
Examine design: T.C., J.P.Ok., and F.M.v.d.S.; knowledge acquisition: N.J.H.B.; analysis speculation: T.C., J.P.Ok., F.M.v.d.S., and N.J.H.B.; knowledge evaluation/interpretation: R.J.R.G., N.J.H.B., and J.P.Ok.; statistical evaluation: R.J.R.G. and B.J.W.; manuscript preparation: R.J.R.G, N.J.H.B., and J.P.Ok.; manuscript overview: N.J.H.B., J.P.Ok., T.C., F.M.v.d.S., and B.J.W.; supervision and mentorship: N.J.H.B. and J.P.Ok.
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Rens J.R. Gadaen
Division of Nephrology, Division of Inner Medication
Maastricht College Medical Middle+, Postbus 5800
NL–6202AZ Maastricht (The Netherlands)
Article / Publication Particulars
First-Web page Preview
Acquired: January 28, 2020
Accepted: August 03, 2020
Revealed on-line: October 27, 2020
Problem launch date: January 2021
Variety of Print Pages: 11
Variety of Figures: 2
Variety of Tables: 6
ISSN: 1660-8151 (Print)
eISSN: 2235-3186 (On-line)
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