Publications by authors named "Kerri L Cavanaugh"

77 Publications

Parent Activation in the Neonatal Intensive Care Unit.

Am J Perinatol 2021 Oct 12. Epub 2021 Oct 12.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.

Objective:  Patient activation is the knowledge, skills, and confidence to manage one's health; parent activation is a comparable concept related to a parent's ability to manage a child's health. Activation in adults is a modifiable risk factor and associated with clinical outcomes and health care utilization. We examined activation in parents of hospitalized newborns observing temporal trends and associations with sociodemographic characteristics, neonate characteristics, and outcomes.

Study Design:  Participants included adult parents of neonates admitted to a level-IV neonatal intensive care unit in an academic medical center. Activation was measured with the 10-item Parent version of the Patient Activation Measure (P-PAM) at admission, discharge, and 30 days after discharge. Associations with sociodemographic variables, health literacy, clinical variables, and health care utilization were evaluated.

Results:  A total of 96 adults of 64 neonates were enrolled. The overall mean P-PAM score on admission was 81.8 (standard deviation [SD] = 18), 88.8 (SD = 13) at discharge, and 86.8 (SD = 16) at 30-day follow-up. Using linear mixed regression model, P-PAM score was significantly associated with timing of measurement. Higher P-PAM scores were associated with higher health literacy ( = 0.002) and higher in mothers compared to fathers ( = 0.040). There were no significant associations of admission P-PAM scores with sociodemographic characteristics. Parents of neonates who had a surgical diagnosis had a statistically significant ( = 0.003) lower score than those who did not. There were no associations between discharge P-PAM scores and neonates' lengths of stay or other indicators of illness severity.

Conclusion:  Parental activation in the NICU setting was higher than reported in the adult and limited pediatric literature; scores increased from admission to discharge and 30-day postdischarge. Activation was higher in mothers and parents with higher health literacy. Additional larger scale studies are needed to determine whether parental activation is associated with long-term health care outcomes as seen in adults.

Key Points: · Little is known about activation in parents of neonates.. · Activation plays a role in health outcomes in adults.. · Larger studies are needed to explore parent activation..
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http://dx.doi.org/10.1055/s-0041-1736294DOI Listing
October 2021

Sincere Integration of Patients' Perspectives into Kidney Care: Affirming and Adopting Patient Activation.

Clin J Am Soc Nephrol 2021 06 11;16(6):840-842. Epub 2021 Jun 11.

Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee

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http://dx.doi.org/10.2215/CJN.05050421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216604PMC
June 2021

Patient-Defined Outcome Endpoints: A Paradigm Shift in Evaluating Atrial Fibrillation Ablation Efficacy.

Heart Lung Circ 2021 Aug 3;30(8):1103-1106. Epub 2021 Jun 3.

Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, TN, USA.

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http://dx.doi.org/10.1016/j.hlc.2021.05.089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254756PMC
August 2021

Multi-Institutional Implementation of Clinical Decision Support for and Genotyping in Antihypertensive Management.

J Pers Med 2021 May 27;11(6). Epub 2021 May 27.

Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.

(1) Background: Clinical decision support (CDS) is a vitally important adjunct to the implementation of pharmacogenomic-guided prescribing in clinical practice. A novel CDS was sought for the , , and genes to guide optimal selection of antihypertensive medications among the African American population cared for at multiple participating institutions in a clinical trial. (2) Methods: The CDS committee, made up of clinical content and CDS experts, developed a framework and contributed to the creation of the CDS using the following guiding principles: 1. medical algorithm consensus; 2. actionability; 3. context-sensitive triggers; 4. workflow integration; 5. feasibility; 6. interpretability; 7. portability; and 8. discrete reporting of lab results. (3) Results: Utilizing the principle of discrete patient laboratory and vital information, a novel CDS for , , and was created for use in a multi-institutional trial based on a medical algorithm consensus. The alerts are actionable and easily interpretable, clearly displaying the purpose and recommendations with pertinent laboratory results, vitals and links to ordersets with suggested antihypertensive dosages. Alerts were either triggered immediately once a provider starts to order relevant antihypertensive agents or strategically placed in workflow-appropriate general CDS sections in the electronic health record (EHR). Detailed implementation instructions were shared across institutions to achieve maximum portability. (4) Conclusions: Using sound principles, the created genetic algorithms were applied across multiple institutions. The framework outlined in this study should apply to other disease-gene and pharmacogenomic projects employing CDS.
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http://dx.doi.org/10.3390/jpm11060480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8226809PMC
May 2021

Impact of pre-dialysis nephrology care engagement and decision-making on provider and patient action toward permanent vascular access.

BMC Nephrol 2021 02 16;22(1):60. Epub 2021 Feb 16.

Duke University Medical Center, Durham, NC, UK.

Background: While catheters are often thought the result of emergency hemodialysis (HD) initiation among patients with little or no pre-dialysis nephrology care, the role of patient level of engagement in care and modality decision-making have not been fully explored.

Methods: This is a retrospective medical record review of adults (age 18-89 years) who received care in academically affiliated private practice, public hospital, or Veterans Administration settings prior to initiating HD with a catheter between 10/1/2011 and 9/30/2012. Primary predictors were level of patient engagement in nephrology care within 6 months of HD initiation and timing of modality decision-making. Primary outcomes were provider action (referral) and any patient action (evaluation by a vascular surgeon, vein mapping or vascular surgery) toward [arteriovenous fistula or graft, (AVF/AVG)] creation.

Results: Among 92 incident HD patients, 66% (n = 61) initiated HD via catheter, of whom 34% (n = 21) had ideal engagement in care but 42% (n = 25) had no documented decision. Providers referred 48% (n = 29) of patients for AVF/AVG, of whom 72% (n = 21) took any action. Ideal engagement in care predicted provider action (adjusted OR 13.7 [95% CI 1.08, 175.1], p = 0.04), but no level of engagement in care predicted patient action (p > 0.3). Compared to patients with no documented decision, those with documented decisions within 3, 3-12, or more than 12 months before initiating dialysis were more likely to have provider action toward AVF/AVG (adjusted OR [95% CI]: 9.0 [1.4,55.6], p = 0.2, 37.6 [3.3423.4] p = 0.003, and 4.8 [0.8, 30.6], p = 0.1, respectively); and patient action (adjusted OR [95% CI]: 18.7 [2.3, 149.0], p = 0.006, 20.4 [2.6, 160.0], p = 0.004, and 6.2 [0.9, 44.0], p = 0.07, respectively).

Conclusions: Timing of patient modality decision-making, but not level of engagement in pre-dialysis nephrology care, was predictive of patient and provider action toward AVF/AVG Interventions addressing patients' psychological preparation for dialysis are needed.
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http://dx.doi.org/10.1186/s12882-021-02264-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885501PMC
February 2021

Religion, Spirituality, and Risk of End-Stage Kidney Disease Among Adults of Low Socioeconomic Status in the Southeastern United States.

J Health Care Poor Underserved 2020 ;31(4):1727-1746

Background: Religiosity, encompassing spirituality and religious practices, is associated with reduced disease incidence among individuals of low socioeconomic status and who self-identify as Black. We hypothesized that religiosity associates with reduced end-stage kidney disease (ESKD) risk among Black but not White adults of low socioeconomic status.

Design: Cox models of religiosity and ESKD risk in 76,443 adults.

Results: Black adults reporting high spirituality had reduced ESKD risk after adjusting for demographic characteristics [Hazard Ratio (HR) .82 (95% Confidence Interval (CI)) (.69-.98)], depressive symptoms, social support, and tobacco use [HR .81 (CI .68-.96)]. When clinical covariates were added, associations between spirituality and ESKD were slightly attenuated and lost significance [HR .85 (CI .68-1.06)]. Associations were not demonstrated among White adults.

Conclusions: Spirituality associates with reduced ESKD risk among Black adults of low socioeconomic status independent of demographic, psychosocial, and behavioral characteristics. Effect modification by race was not statistically significant.
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http://dx.doi.org/10.1353/hpu.2020.0129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874531PMC
September 2021

Health Education in Schools as a Perpetual Priority to Prevent Kidney Disease.

Kidney Int Rep 2020 Dec 1;5(12):2130-2132. Epub 2020 Nov 1.

Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

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http://dx.doi.org/10.1016/j.ekir.2020.10.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710889PMC
December 2020

Provider Attitudes and Support of Patients' Autonomy for Phosphate Binder Medication Adherence in ESRD.

J Patient Exp 2020 Oct 19;7(5):708-712. Epub 2019 Nov 19.

Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.

This cross-sectional study of 56 dialysis providers from 3 dialysis clinics examined providers' attitudes and perception of autonomy support for patients' medication adherence behaviors. Respondents completed surveys assessing attitudes and perception of autonomy support. Compared to all other provider types, physicians and nurse practitioners (MD/NP) thought it was "less true" that phosphate binder medications are very important for dialysis patients (MD/NP vs others: 5.1 [1.4] vs 6.1 [1.1]; = 0.02). More dialysis technicians (19%) offered the highest level of support. Attitudes and perception of autonomy support for medication adherence are suboptimal, vary by dialysis provider type, and are targets for quality improvement in dialysis care. This study addresses critical gap in existing knowledge about these two novel provider-based psychosocial factors and their potential impact on phosphate binder medication adherence.
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http://dx.doi.org/10.1177/2374373519883502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705840PMC
October 2020

Barriers to home dialysis: Unraveling the tapestry of policy.

Semin Dial 2020 Nov 19;33(6):499-504. Epub 2020 Nov 19.

Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.

Home dialysis use as a treatment for end-stage kidney disease varies locally, nationally, and internationally. There is a call to action in the United States to significantly increase access and uptake of home dialysis as the preferred dialysis treatment option. Although most do not object to patient choice in modality selection, the reality is that there are multilevel barriers both obvious and subtle that interfere with expanding home dialysis access. Financial barriers and how payment is structured continue to be key drivers, although new models of care are emerging that include for the first time incentives rather than penalties regarding home dialysis. Resources to support implementation include expert personnel requiring educational training. Policies requiring training curriculum content that is not only specified within nephrology but also for these multidisciplinary providers requisite for successful home dialysis to ensure professional expertise is ready and available, and also to cultivate champions of home modality within the broader nephrology community. Perhaps most importantly, innovation through expanded investment in research is necessary to advance practices, elevate quality, and improve outcomes. Policy in a variety of sectors at local, regional, national, and international levels has the potential to drastically drive expansion and increasing success of home dialysis.
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http://dx.doi.org/10.1111/sdi.12939DOI Listing
November 2020

Interventions Incorporating Therapeutic Alliance to Improve Hemodialysis Treatment Adherence in Black Patients with End-Stage Kidney Disease (ESKD) in the United States: A Systematic Review.

Patient Prefer Adherence 2020 17;14:1435-1444. Epub 2020 Aug 17.

Vanderbilt Center for Kidney Disease, Nashville, TN, USA.

Background: In the US, Blacks with end-stage kidney disease (ESKD) have a four-fold higher prevalence rate of hemodialysis treatment and higher subsequent rates of hemodialysis treatment nonadherence and hospitalization compared to their White peers. Nonadherence to prescribed dialysis therapy is an underestimated life-threatening behavior, because of its association with increased morbidity and mortality. Few studies have specified and systematically evaluated targeted methods of increasing hemodialysis treatment adherence among Black hemodialysis patients with added focus on therapeutic alliance, a rewarding patient-centered relationship between patients and providers, based on common goals and objectives. This review seeks to evaluate the state of the science to determine the salience of a therapeutic alliance for the development of effective interventions positively impacting hemodialysis treatment adherence among Black patients.

Methods: Medline (via PubMed), Embase (OvidSP), Cumulative Index of Nursing and Allied Health Literature (CINAHL; EBSCOhost), and PsycInfo (ProQuest) databases were used to search for abstracts with the keywords "dialysis", "therapeutic alliance", and "treatment adherence and compliance", including all underlying index terms and alternative variations of terms, in order to cover the entire scope of the field. Only randomized clinical trials and pre/postintervention studies published in the previous 10 years (2009-2019) and including a proportion of Black patients >25% were included for review.

Results: Only three intervention studies met these criteria, for a total aggregated sample of 130 - mean age 58.1 years and 53% female. None of these studies was composed exclusively of Black patients (range 62%-91.3%), nor did they present data specifically for Blacks. Despite the lack of robust data informing strategies to improve hemodialysis adherence among Blacks with ESRD, a limited number of intervention studies have reported positive effects on hemodialysis attendance.

Discussion/conclusion: Further research is warranted to fill this significant gap in our understanding of theoretically based, therapeutic alliance-enhanced, and culturally tailored hemodialysis treatment-adherence interventions among Blacks.
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http://dx.doi.org/10.2147/PPA.S260684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7443008PMC
August 2020

Psychological Adaptation to Serious Illness: A Qualitative Study of Culturally Diverse Patients With Advanced Chronic Kidney Disease.

J Pain Symptom Manage 2021 01 22;61(1):32-41.e2. Epub 2020 Jul 22.

Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt O'Brien Center for Kidney Disease, Nashville, Tennessee, USA; Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Context: Psychological distress is associated with adverse health outcomes in serious illness and magnified among patients of low socioeconomic status. Aspects of one's culture, such as religion and spirituality, can influence these patients' coping response to distress. Advanced chronic kidney disease (CKD) is a serious illness that disproportionately affects patients of low socioeconomic status, but a theory-based understanding of this group's lived experience of CKD is lacking.

Objectives: We explored the cognitions, emotions, and coping behaviors of patients with CKD with emphasis on those of low socioeconomic status. We further inquired into any influences of religion or spirituality.

Methods: We interviewed 50 English-speaking or Spanish-speaking adults with advanced CKD from three medical centers in Nashville, Tennessee. Analyses occurred with isolation of themes; development of a coding system; and creation of a conceptual framework using an inductive-deductive approach.

Results: Median age was 65 years; median annual income was $17,500 per year; and 48% of participants had not progressed beyond high school. Key beliefs (awareness of mortality and lack of control) influenced patients' emotions (existential distress in the form of death anxiety, prognostic uncertainty, and hopelessness) and coping behaviors (acceptance, avoidance, emotion regulation via spirituality, and seeking socialsupport via a religious community).

Conclusion: Individuals with advanced CKD and low socioeconomic status lack control over disease progression, experience death anxiety and existential distress, and emphasize spirituality to cope. Our study identifies novel components for a psychotherapeutic intervention for patients with advanced CKD at high risk for adverse health outcomes.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.07.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770006PMC
January 2021

Community Racial Composition and Hospitalization Among Patients Receiving In-Center Hemodialysis.

Am J Kidney Dis 2020 12 13;76(6):754-764. Epub 2020 Jul 13.

Division of General Internal Medicine, UCLA/David Geffen School of Medicine, Los Angeles, CA; Division of Nephrology, UCLA/David Geffen School of Medicine, Los Angeles, CA.

Rationale & Objective: Community racial composition has been shown to be associated with mortality in patients receiving maintenenance dialysis. It is unclear whether living in communities with predominantly Black residents is also associated with risk for hospitalization among patients receiving hemodialysis.

Study Design: Retrospective analysis of prospectively collected data from a cohort of patients receiving hemodialysis.

Setting & Participants: 4,567 patients treated in 154 dialysis facilities located in 127 unique zip codes and enrolled in US Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4 to 5 (2010-2015).

Exposure: Tertile of percentage of Black residents within zip code of patients' dialysis facility, defined through a link to the American Community Survey.

Outcome: Rate of hospitalizations during the study period.

Analytic Approach: Associations of patient-, facility-, and community-level variables with community's percentage of Black residents were assessed using analysis of variance, Kruskal-Wallis, or χ/Fisher exact tests. Negative binomial regression was used to estimate the incidence rate ratio for hospitalizations between these communities, with and without adjustment for potential confounding variables.

Results: Mean age of study patients was 62.7 years. 53% were White, 27% were Black, and 45% were women. Median and threshold percentages of Black residents in zip codes in which dialysis facilities were located were 34.2% and≥14.4% for tertile 3 and 1.0% and≤1.8% for tertile 1, respectively. Compared with those in tertile 1 facilities, patients in tertile 3 facilities were more likely to be younger, be Black, live in urban communities with lower socioeconomic status, have a catheter as vascular access, and have fewer comorbid conditions. Patients dialyzing in communities with the highest tertile of Black residents experienced a higher adjusted rate of hospitalization (adjusted incidence rate ratio, 1.32; 95% CI, 1.12-1.56) compared with those treated in communities within the lowest tertile.

Limitations: Potential residual confounding.

Conclusions: The risk for hospitalization for patients receiving maintenance dialysis is higher among those treated in communities with a higher percentage of Black residents after adjustment for dialysis care, patient demographics, and comorbid conditions. Understanding the cause of this association should be a priority of future investigation.
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http://dx.doi.org/10.1053/j.ajkd.2020.05.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844565PMC
December 2020

Measuring Patient Activation as Part of Kidney Disease Policy: Are We There Yet?

J Am Soc Nephrol 2020 07 11;31(7):1435-1443. Epub 2020 Jun 11.

Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

Optimal care occurs when patients possess the skills, knowledge, and confidence needed to effectively manage their health. Promoting such patient activation in kidney disease care is increasingly being prioritized, and patient activation has recently emerged as central to kidney disease legislative policy in the United States. Two options of the Centers for Medicare and Medicaid Services Kidney Care Choices model-the Kidney Care First option and the Comprehensive Kidney Care Contracting option-now include patient activation as a quality metric; both models specifically name the patient activation measure (PAM) as the patient-reported outcome to use when assessing activation in kidney disease. Because nephrology practices participating in these models will receive capitated payments according to changes in patients' PAM scores, it is time to more critically evaluate this measure as it applies to patients with kidney disease. In this review, we raise important issues related to the PAM's applicability to kidney health, review and summarize existing literature that applies this measure to patients with kidney disease, and outline key elements to consider when implementing the PAM into practice and policy. Our aim is to spur further dialogue regarding how to assess and address patient activation in kidney disease to facilitate best practices for supporting patients in the successful management of their kidney health.
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http://dx.doi.org/10.1681/ASN.2019121331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350992PMC
July 2020

At the Research-Clinical Interface: Returning Individual Genetic Results to Research Participants.

Clin J Am Soc Nephrol 2020 08 10;15(8):1181-1189. Epub 2020 Feb 10.

Department of Bioethics and Humanities and

Whether individual results of genetic research studies ought to be disclosed to study participants has been debated in recent decades. Previously, the prevailing expert view discouraged the return of individual research results to participants because of the potential lack of analytic validity, questionable clinical validity and medical actionability, and questions about whether it is the role of research to provide participants with their data. With additional knowledge of participant perspectives and shifting views about the benefits of research and respect for participants, current expert consensus is moving toward support of returning such results. Significant ethical controversies remain, and there are many practical questions left to address, including appropriate procedures for returning results and the potential burden to clinicians when patients seek guidance about the clinical implications of research results. In this review, we describe current views regarding the return of genetic research results, including controversies and practical challenges, and consider the application of these issues to research on apolipoprotein L1 (), a gene recently associated with health disparities in kidney disease. Although this case is unique, it illustrates the complexities involved in returning results and highlights remaining questions.
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http://dx.doi.org/10.2215/CJN.09670819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409748PMC
August 2020

Incorporating patient-reported outcomes (PROs) into dialysis policy: Current initiatives, challenges, and opportunities.

Semin Dial 2020 01;33(1):18-25

Vanderbilt Center for Kidney Disease, Nashville, TN, USA.

Governments at national and state levels regulate dialysis care in the United States to ensure safe practices, and continually elevate the quality of care. An objective of these regulatory policies is the independent evaluation of dialysis unit outcomes by patients, caregivers, and the community to facilitate choices as well as to advance equal access to high quality dialysis care. These polices recognized decades ago that it was fundamental to include the patient perspective in the assessment and evaluation of dialysis care quality by requiring both individual and aggregate patient reported outcomes (PROs). Although there is support for integrating the patient perspective, concerns persist about the implementation of these polices including selection of PRO measures, administration timing and reach, as well as interpretation of results including benchmarking to permit comparisons across organizations. The experience from the early adoption of PROs into dialysis policies in conjunction with advances in electronic health records, personal data capture and monitoring, and analytics is poised to address these concerns. The dialysis community has the opportunity to lead the way in innovation related to PRO implementation not only in kidney disease care, but also for other healthcare conditions or contexts such as oncology, surgical, and acute care.
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http://dx.doi.org/10.1111/sdi.12854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7017723PMC
January 2020

The Relationship of Disease-Specific Knowledge and Health Literacy With the Uptake of Self-Care Behaviors in CKD.

Kidney Int Rep 2020 Jan 17;5(1):48-57. Epub 2019 Oct 17.

Division of Nephrology, University of Michigan Medical School, Ann Arbor, Michigan, USA.

Introduction: Individuals with chronic kidney disease (CKD) generally have poor participation in self-care. We hypothesized that greater kidney disease knowledge and health literacy would associate with better self-care.

Methods: We enrolled 401 participants with non-dialysis-dependent CKD from one academic center in this cross-sectional study. Validated surveys were used to assess health literacy level (inadequate vs. adequate; Rapid Estimate of Adult Literacy in Medicine), perceived kidney disease knowledge (Perceived Kidney Disease Knowledge Survey [PiKS]), objective kidney disease knowledge (Kidney Disease Knowledge Survey [KiKS]), and a CKD self-care measure was constructed as the sum of self-reported self-care behaviors using the adapted Summary of Diabetes Self-Care Activities Assessment. The association between health literacy level, PiKS scores, KiKS scores, and the CKD self-care measure was assessed with multivariable adjusted linear regression models.

Results: Participants had a mean age of 57 years and 17.7% had inadequate health literacy. PiKS scores were positively associated with the CKD self-care measure (β = 1.05, 95% confidence interval [CI] 0.50-1.63), and a positive trend was observed for KiKS scores and the CKD self-care measure (β = 0.30, 95% CI: -0.12 to 0.72). Health literacy was not associated with CKD self-care measure.

Conclusion: Objective kidney disease knowledge is likely necessary, but not sufficient for self-care and may depend on the level of health literacy. Perceived kidney knowledge may offer a novel target to assess patients at risk for poor self-care, and be used in targeted educational interventions.
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http://dx.doi.org/10.1016/j.ekir.2019.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6943760PMC
January 2020

Apolipoprotein L1 Testing in African Americans: Involving the Community in Policy Discussions.

Am J Nephrol 2019 3;50(4):303-311. Epub 2019 Sep 3.

Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA.

Background: Apolipoprotein A1 (APOL1) gene variants occurring in people of West African descent contribute to the greater burden of kidney disease among African Americans. These variants are associated with increased risk of nondiabetic nephropathy, more rapid progression of chronic kidney disease, and shorter survival of donor kidneys after transplantation. However, only a minority of people with APOL1-associated risk develops kidney disease and specific clinical measures to address APOL1-associated risk are lacking. Given these uncertainties, we sought to engage members of the African American public in discussions with other stakeholders about the appropriate use of APOL1 testing.

Methods: Formative interviews with community members, researchers, and clinicians in Seattle WA, Nashville TN, and Jackson MS, provided baseline information about views toward APOL1 testing and informed the design of 3 community-based deliberations among African Americans. A national meeting held in March 2018 included 13 community members, 7 scientific advisors and 26 additional researchers, clinicians, bioethicists, patient advocates, and representatives from professional organizations and federal funding agencies. Using small break-out and plenary discussion, the group agreed on recommendations based on current knowledge about APOL1-associated risk.

Results: Meeting outcomes included recommendations to develop educational materials about APOL1 for community members and clinicians; to offer APOL1 research results to participants; and on the use of APOL1testing in kidney transplant programs. The group recommended against the routine offer of APOL1 testing in clinical care. Areas of disagreement included whether kidney transplant programs should require APOL1 testing of prospective living donors or bar individuals with APOL1 risk from donating kidneys and whether testing should be available on request in routine clinical care.

Conclusion: We recommend continued discussion among stakeholders and concerted efforts to ensure active and informed participation of members of the affected community to guide research on APOL1 and kidney disease.
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http://dx.doi.org/10.1159/000502675DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783335PMC
September 2020

Racial disparities in end-stage renal disease in a high-risk population: the Southern Community Cohort Study.

BMC Nephrol 2019 08 7;20(1):308. Epub 2019 Aug 7.

Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave, Ste 600, Nashville, TN, 37203, USA.

Introduction: The Southern Community Cohort Study is a prospective study of low socioeconomic status (SES) blacks and whites from the southeastern US, where the burden of end-stage renal disease (ESRD) and its risk factors are high. We tested whether the 2.4-fold elevated risk of ESRD we previously observed in blacks compared to whites was explained by differences in baseline kidney function.

Methods: We conducted a case-cohort study of incident ESRD cases (n = 737) with stored blood and a probability sampled subcohort (n = 4238) and calculated estimated glomerular filtration rate (eGFR) from serum creatinine. 86% of participants were enrolled from community health centers in medically underserved areas and 14% from the general population in 12 states in the southeastern United States. Incident ESRD after entry into the cohort was ascertained by linkage of the cohort with the US Renal Data System (USRDS).

Results: Median (25th, 75th percentile) eGFR at baseline was 63.3 (36.0, 98.2) ml/min/1.73m for ESRD cases and 103.2 (86.0, 117.9) for subcohort. Black ESRD cases had higher median (25th, 75th) eGFR [63.3 (35.9, 95.9)] compared to whites [59.1 (39.4, 99.2)]. In multivariable Cox models accounting for sampling weights, baseline eGFR was a strong predictor of ESRD risk, and an interaction with race was detected (P = 0.029). The higher ESRD risk among blacks relative to whites persisted (hazard ratio: 2.58; 95% confidence interval: 1.65, 4.03) after adjustment for eGFR.

Conclusion: In this predominantly lower SES cohort, the racial disparity in ESRD risk is not explained by differences in baseline kidney function.
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http://dx.doi.org/10.1186/s12882-019-1502-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686512PMC
August 2019

Public Policy and Equal Access to Home Dialysis.

Clin J Am Soc Nephrol 2019 Aug 18;14(8):1128-1130. Epub 2019 Jul 18.

Division of Nephrology and Hypertension, Department of Medicine and

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http://dx.doi.org/10.2215/CJN.07560719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682828PMC
August 2019

Kidney Disease Awareness and Knowledge among Survivors ofAcute Kidney Injury.

Am J Nephrol 2019 17;49(6):449-459. Epub 2019 Apr 17.

Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt Center for Kidney Diseases (VCKD) and Integrated Program for AKI Research (VIP-AKI), Nashville, Tennessee, USA.

Background: Acute kidney injury (AKI) survivors are at risk for chronic kidney disease, recurrent AKI, and cardiovascular disease. The transition from hospital to ambulatory care is an opportunity to reduce these sequelae by launching self-care plans through effective patient education. How well AKI survivors are informationally prepared to apply kidney-specific self-care is unknown. The purpose of this study was to identify awareness and disease-specific knowledge among AKI survivors.

Methods: We performed a cross-sectional survey of AKI-related awareness and knowledge in 137 patients with Kidney Disease Improving Global Outcomes Stage II or III AKI near the time of hospital discharge. Patients were asked (1) "Did you experience AKI while in the hospital?" and (2) "Do you have a problem with your kidney health?" Objective knowledge of AKI was evaluated with a 15-item adapted version of the validated Kidney Knowledge Survey that included topics such as common causes, risk factors, and how AKI is diagnosed.

Results: Median age was 54 (interquartile range 43-63) and 81% were white. Eighty percent of patients were unaware that they had experienced AKI and 53% were both unaware they had experienced AKI or had a "problem with their kidneys." Multivariable logistic regression identified being male and lack of nephrology consult as predictors of unawareness with ORs of 3.92 (95% CI 1.48-10.33) and 5.10 (95% CI 1.98-13.13), respectively. Less than 50% recognized nonsteroidal anti-inflammatory drugs, contrast, or phosphate-based cathartics as risk factors for AKI. Two-thirds of patients did not agree that they knew a lot about AKI and more than 80% desired more information.

Conclusions: Most patients with moderate to severe AKI are unaware of their condition, lack understanding of risk factors for recurrent AKI, and desire more information. Patient-centered communication to optimize awareness, understanding, and care will require coordinated educational strategies throughout the continuum of AKI care.
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http://dx.doi.org/10.1159/000499862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679978PMC
July 2020

Correction to: Health care providers' support of patients' autonomy, phosphate medication adherence, race and gender in end-stage renal disease.

J Behav Med 2019 Apr;42(2):376-379

Division of Nephrology and Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue MCN S-3223, Nashville, TN, 37232, USA.

In the original publication of the article, the majority of changes stem from misclassification of "medium adherence" when using the Morisky Medication Adherence Scale (MMAS-8) and not using the correct scoring algorithm for one of the responses when calculating MMAS-8 total scores.
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http://dx.doi.org/10.1007/s10865-018-9992-xDOI Listing
April 2019

Audio-/Videorecording Clinic Visits for Patient's Personal Use in the United States: Cross-Sectional Survey.

J Med Internet Res 2018 09 12;20(9):e11308. Epub 2018 Sep 12.

The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, United States.

Background: Few clinics in the United States routinely offer patients audio or video recordings of their clinic visits. While interest in this practice has increased, to date, there are no data on the prevalence of recording clinic visits in the United States.

Objective: Our objectives were to (1) determine the prevalence of audiorecording clinic visits for patients' personal use in the United States, (2) assess the attitudes of clinicians and public toward recording, and (3) identify whether policies exist to guide recording practices in 49 of the largest health systems in the United States.

Methods: We administered 2 parallel cross-sectional surveys in July 2017 to the internet panels of US-based clinicians (SERMO Panel) and the US public (Qualtrics Panel). To ensure a diverse range of perspectives, we set quotas to capture clinicians from 8 specialties. Quotas were also applied to the public survey based on US census data (gender, race, ethnicity, and language other than English spoken at home) to approximate the US adult population. We contacted 49 of the largest health systems (by clinician number) in the United States by email and telephone to determine the existence, or absence, of policies to guide audiorecordings of clinic visits for patients' personal use. Multiple logistic regression models were used to determine factors associated with recording.

Results: In total, 456 clinicians and 524 public respondents completed the surveys. More than one-quarter of clinicians (129/456, 28.3%) reported that they had recorded a clinic visit for patients' personal use, while 18.7% (98/524) of the public reported doing so, including 2.7% (14/524) who recorded visits without the clinician's permission. Amongst clinicians who had not recorded a clinic visit, 49.5% (162/327) would be willing to do so in the future, while 66.0% (346/524) of the public would be willing to record in the future. Clinician specialty was associated with prior recording: specifically oncology (odds ratio [OR] 5.1, 95% CI 1.9-14.9; P=.002) and physical rehabilitation (OR 3.9, 95% CI 1.4-11.6; P=.01). Public respondents who were male (OR 2.11, 95% CI 1.26-3.61; P=.005), younger (OR 0.73 for a 10-year increase in age, 95% CI 0.60-0.89; P=.002), or spoke a language other than English at home (OR 1.99; 95% CI 1.09-3.59; P=.02) were more likely to have recorded a clinic visit. None of the large health systems we contacted reported a dedicated policy; however, 2 of the 49 health systems did report an existing policy that would cover the recording of clinic visits for patient use. The perceived benefits of recording included improved patient understanding and recall. Privacy and medicolegal concerns were raised.

Conclusions: Policy guidance from health systems and further examination of the impact of recordings-positive or negative-on care delivery, clinician-related outcomes, and patients' behavioral and health-related outcomes is urgently required.
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http://dx.doi.org/10.2196/11308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231772PMC
September 2018

Phosphate-control adherence in hemodialysis patients: current perspectives.

Patient Prefer Adherence 2018 4;12:1175-1191. Epub 2018 Jul 4.

Vanderbilt Center for Kidney Disease, Nashville, TN, USA,

Objectives: This review summarizes factors relevant for adherence to phosphate-control strategies in dialysis patients, and discusses interventions to overcome related challenges.

Methods: A literature search including the terms "phosphorus", "phosphorus control", "hemo-dialysis", "phosphate binder medications", "phosphorus diet", "adherence", and "nonadherence" was undertaken using PubMed, PsycInfo, CINAHL, and Embase.

Results: Hyperphosphatemia is associated with cardiovascular and all-cause mortality in dialysis patients. Management of hyperphosphatemia depends on phosphate binder medication therapy, a low-phosphorus diet, and dialysis. Phosphate binder therapy is associated with a survival benefit. Dietary restriction is complex because of the need to maintain adequate protein intake and, alone, is insufficient for phosphorus control. Similarly, conventional hemodialysis alone is insufficient for phosphorus control due to the kinetics of dialytic phosphorus removal. Thus, all three treatment approaches are important contributors, with dietary restriction and dialysis as adjuncts to the requisite phosphate binder therapy. Phosphate-control adherence rates are suboptimal and are influenced directly by patient, provider, and phosphorus-control strategy-related factors. Psychosocial factors have been implicated as influential "drivers" of adherence behaviors in dialysis patients, and factors based on self-motivation associate directly with adherence behavior. Higher-risk subgroups of nonadherent patients include younger dialysis patients and non-whites. Provider attitudes may be important - yet unaddressed - determinants of adherence behaviors of dialysis patients.

Conclusion: Adherence to phosphate binders, low-phosphorus diet, and dialysis prescription is suboptimal. Multicomponent strategies that concurrently address therapy-related factors such as side effects, patient factors targeting self-motivation, and provider factors to improve attitudes and delivery of culturally sensitive care show the most promise for long-term control of phosphorus levels. Moreover, it will be important to identify patients at highest risk for lack of control, and for programs to be ready to deliver flexible person-centered strategies through training and dedicated resources to align with the needs of all patients.
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http://dx.doi.org/10.2147/PPA.S145648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039061PMC
July 2018

Validation of the shortened Perceived Medical Condition Self-Management Scale in patients with chronic disease.

Psychol Assess 2018 Oct 21;30(10):1300-1307. Epub 2018 May 21.

Vanderbilt School of Nursing, Vanderbilt University.

Self-efficacy, or perceived competence, has been identified as an important factor in self-management behaviors and health outcomes in patients with chronic disease. Measures of self-management self-efficacy are currently available for multiple forms of chronic disease. One established measure is the 8-item Perceived Medical Condition Self-Management Scale (PMCSMS). This study investigated the use of the PMCSMS in samples of patients with a chronic disease to develop an abbreviated version of the scale that could be more readily used in clinical contexts or in large population health cohort studies. The PMCSMS was administered as either a generic scale or as a disease-specific scale. The results of analyses using item response theory and classical test theory methods indicated that using 4 items of the scale resulted in similar internal consistency (α = .70-0.90) and temporal stability (test-retest r = .75 after 2 to 4 weeks) to the 8-item PMCSMS (r = .81 after 2 to 4 weeks). The 4 items selected had the greatest discriminability among participants (α parameters = 2.49-3.47). Scores from both versions also demonstrated similar correlations with related constructs such as health literacy (r = .13-0.29 vs. 0.14-0.27), self-rated health (r = .17-0.48 vs. 0.26-0.50), social support (r = .21-0.32 vs. 0.25-0.34), and medication adherence (r = .20-0.24 vs. 0.20-0.25). The results of this study indicate that 4-item PMCSMS scores are equally valid but more efficient, and have the potential to be beneficial for both research and clinical applications. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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http://dx.doi.org/10.1037/pas0000572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6172142PMC
October 2018

Protein Intake and Long-term Change in Glomerular Filtration Rate in the Jackson Heart Study.

J Ren Nutr 2018 07 13;28(4):245-250. Epub 2018 Feb 13.

Vanderbilt Center for Kidney Disease, Nashville, Tennessee; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Objective: Dietary protein intake could have deleterious renal effects in populations at risk for chronic kidney disease. Here, we examined whether higher protein intake (≥80th percentile of energy from protein) is associated with decline in kidney function and whether this decline varies by diabetes status.

Design: Observational cohort study.

Subjects And Settings: Participants were African-Americans (n = 5,301), who enrolled in the Jackson Heart Study between 2000 and 2004.

Methods: Dietary intake was assessed using a validated food-frequency questionnaire at baseline, and serum creatinine was measured at baseline (visit 1) and 8 years later (visit 3). Estimated glomerular filtration rates (eGFRs) at baseline and follow-up were computed using the chronic kidney disease epidemiology collaboration equation.

Main Outcome Measure: The change in eGFR was computed by subtracting eGFR at visit 1 from that at visit 3.

Results: Of 3,165 participants with complete data, 64% were women, 57% had hypertension, and 19% had diabetes. The median (25th, 75th percentile) percent energy intake from protein was 14.3 (12.4, 16.4), comparable to that reported for the general US population (15% of energy). During a median (25th, 75th percentile) follow-up of 8.0 (7.4, 8.3) years, eGFR declined by 10.5% from a mean (SD) of 97.4 (17.5) to 86.9 (21.3) mL/min/1.73 m. In the fully adjusted model, consumption of protein as percent of energy intake in lowest and highest quintiles was associated with decline in eGFR among diabetic subjects. The analysis of variance with a robust variance estimator was used to determine whether long-term change in eGFR significantly varies by protein intake.

Conclusions: Our results show that, among African-Americans with diabetes, higher protein intake as a percent of total energy intake is positively associated with greater decline in eGFR in analyses that accounted for risk factors for kidney disease.
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http://dx.doi.org/10.1053/j.jrn.2017.11.008DOI Listing
July 2018

The Perceived Medical Condition Self-Management Scale can be applied to patients with chronic kidney disease.

Kidney Int 2017 10 18;92(4):972-978. Epub 2017 May 18.

Vanderbilt University Medical Center, Nashville, Tennessee, USA; Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA. Electronic address:

Chronic Kidney Disease (CKD) is a major burden on patients and the health care system. Treatment of CKD requires dedicated involvement from both caretakers and patients. Self-efficacy, also known as perceived competence, contributes to successful maintenance of patient's CKD self-management behaviors such as medication adherence and dietary regulations. Despite a clear association between self-efficacy and improved CKD outcomes, there remains a lack of validated self-report measures of CKD self-efficacy. To address this gap, the Perceived Kidney/Dialysis Self-Management Scale (PKDSMS) was adapted from the previously validated Perceived Medical Condition Self-Management Scale. We then sought to validate this using data from two separate cohorts: a cross-sectional investigation of 146 patients with end-stage renal disease receiving maintenance hemodialysis and a longitudinal study of 237 patients with CKD not receiving dialysis. The PKDSMS was found to be positively and significantly correlated with self-management behaviors and medication adherence in both patient cohorts. The PKDSMS had acceptable reliability, was internally consistent, and exhibited predictive validity between baseline PKDSMS scores and self-management behaviors across multiple time points. Thus, the PKDSMS is a valid and reliable measure of CKD patient self-efficacy and supports the development of interventions enhancing perceived competence to improve CKD self-management.
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http://dx.doi.org/10.1016/j.kint.2017.03.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5610608PMC
October 2017

Dietary polyunsaturated fatty acids and incidence of end-stage renal disease in the Southern Community Cohort Study.

BMC Nephrol 2016 10 18;17(1):152. Epub 2016 Oct 18.

Vanderbilt Center for Kidney Disease, Nashville, TN, 37232, USA.

Background: Whether polyunsaturated fatty acids (PUFA) are associated with end-stage renal disease (ESRD) in populations with a high burden of risk factors for kidney disease is unknown. We sought to determine whether PUFA intake is associated with ESRD.

Methods: We conducted a nested case-control study of ESRD within the Southern Community Cohort Study (SCCS), a prospective cohort of low-income blacks and whites in the southeastern US (2002-2009). Through 2012, 1,074 incident ESRD cases were identified by linkage with the United States Renal Data System and matched to 3,230 controls by age, sex and race. Dietary intake of total, n-3 or n-6 PUFA was assessed from a validated food frequency questionnaire administered at baseline. Odds ratios (ORs) and 95 % confidence intervals (CIs) were computed from logistic regression models that included matching variables, body mass index, smoking, diabetes, hypertension, education, income, total energy intake and percent energy from protein and saturated fat.

Results: The mean (SD) age of participants was 55 (9) years. Most participants were women (55 %), black (87 %), with hypertension (67 %) and on average obtained 8 % of their energy from PUFA. Higher PUFA intake was marginally associated with a lower risk of ESRD in adjusted analyses. The adjusted odds ratios (95 % confidence intervals) for ESRD for the 5 vs. 1 quintile of PUFA were 0.79 (0.60-1.05; P  = 0.06) for total PUFA, 0.81 (0.61-1.06; P  = 0.04) for n-6 PUFA and 0.93 (0.71-1.21; P  = 0.45) for n-3 PUFA.

Conclusions: We observed a marginally significant inverse trend between dietary PUFA intake and ESRD incidence, mainly driven by n-6 fatty acid intake. Our findings require replication but suggest that a diet rich in n-6 PUFA may prevent ESRD development in a population with a high burden of kidney disease risk factors.
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http://dx.doi.org/10.1186/s12882-016-0371-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070154PMC
October 2016

Protocol of a randomized controlled trial of an erythropoietin stimulating agent decision aid for anemia treatment in kidney disease.

BMC Nephrol 2016 07 18;17(1):86. Epub 2016 Jul 18.

Division of Nephrology & Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue South, S-3223 MCN, Nashville, TN, 37232, USA.

Background: Erythropoiesis-stimulating agents (ESAs) are commonly used for the treatment of anemia due to chronic kidney disease (CKD) and end stage renal disease (ESRD). Patients often lack an understanding of the potential risks and benefits of ESAs, despite government mandated education on this topic. Decision aids are tools commonly used to discuss important information in health care settings. To address this knowledge gap, we designed this study to evaluate the effectiveness of a novel ESA decision aid at promoting informed shared decision making (ISDM) between patients and providers related to ESA use for CKD- and ESRD-related anemia.

Methods: Using the principles of informed shared decision making theory, we designed and piloted an ESA decision aid intended to increase CKD and ESRD patient understanding of the potential risks and benefits of ESAs. Informed by the findings during development, the ESA decision aid was modified and finalized for testing. We will perform a randomized clinical trial to assess if administration of the ESA decision aid improves patient understanding of the risks and benefits of ESA use compared to control patients receiving standard care. Participants with either CKD or ESRD and who are receiving ESAs will be eligible for participation. The primary outcome is patients' score on the Patient Anemia Knowledge in Kidney Disease (PAKKD) survey assessed at enrollment and 3 months after. Secondary outcomes include decisional conflict related to ESAs, and patient satisfaction with provider communication.

Discussion: The Anemia Risk Communication for patients with Kidney Disease (ARC-KD) study will assess the effectiveness of a novel ESA decision aid to improve patient understanding of ESA use to manage CKD- and ESRD-related anemia. This decision aid is the first resource targeted to improve patient understanding of anemia management in the kidney health context. With the increasing options available for anemia management, this will serve as an important foundation to evolve in the future to optimize anemia-related shared decision making.

Trial Registration: ClinicalTrials.gov, number NCT01992926 . Registered 11/14/2013.
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http://dx.doi.org/10.1186/s12882-016-0301-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949884PMC
July 2016
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