Receive Kidney Replacement Therapy Research Articles

Sex Differences in Age-Related Loss of Kidney Function.

CKD is more prevalent in women, but more men receive kidney replacement therapy for kidney failure. This apparent contradiction is not well understood. We investigated sex differences in the loss of kidney function and whether any sex disparities could be explained by comorbidity or CKD risk factors. In the Renal Iohexol Clearance Survey (RENIS) in northern Europe, we recruited 1837 persons (53% women, aged 50-62 years) representative of the general population and without self-reported diabetes, CKD, or cardiovascular disease. Participants' GFR was measured by plasma iohexol clearance in 2007-2009 (n=1627), 2013-2015 (n=1324), and 2018-2020 (n=1384). At each study visit, healthy persons were defined as having no major chronic diseases or risk factors for CKD. We used generalized additive mixed models to assess age- and sex-specific GFR decline rates. Women had a lower GFR than men at baseline (mean [SD], 90.0 [14.0] versus 98.0 [13.7] ml/min per 1.73 m2; P<0.001). The mean GFR change rate was -0.96 (95% confidence interval [CI], -0.88 to -1.04) ml/min per 1.73 m2 per year in women and -1.20 (95% confidence interval [CI], -1.12 to -1.28) in men. Although the relationship between age and GFR was very close to linear in women, it was curvilinear in men, with steeper GFR slopes at older ages (nonlinear effect; P<0.001). Healthy persons had a slower GFR decline, but health status did not explain the sex difference in the GFR decline. Among middle-aged and elderly individuals in the general population, decline in the mean GFR in women was slower than in men, independent of health status.

Syphilis and gonorrhoea cases soar in US.

<h3>Abstract</h3> <h3>Objective</h3> To evaluate sex differences in mortality among people with kidney failure compared with the general population. <h3>Design</h3> Population based cohort study using data linkage. <h3>Setting</h3> The Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), which includes all patients receiving kidney replacement therapy in Australia (1980-2019) and New Zealand (1988-2019). Data were linked to national death registers to determine deaths and their causes, with additional details obtained from ANZDATA. <h3>Participants</h3> Of 82 844 people with kidney failure, 33 329 were female (40%) and 49 555 were male (60%); 49 376 deaths (20 099 in female patients; 29 277 in male patients) were recorded over a total of 536 602 person years of follow-up. <h3>Main outcome measures</h3> Relative measures of survival, including standardised mortality ratios, relative survival, and years of life lost, using general population data to account for background mortality (adjusting for country, age, sex, and year). Estimates were stratified by dialysis modality (haemodialysis or peritoneal dialysis) and for the subpopulation of kidney transplant recipients. <h3>Results</h3> Few differences in outcomes were found between male and female patients with kidney failure. However, compared with the general population, female patients with kidney failure had greater excess all cause deaths than male patients (female patients: standardised mortality ratio 11.3, 95% confidence interval 11.2 to 11.5, expected deaths 1781, observed deaths 20 099; male patients: 6.9, 6.8 to 6.9, expected deaths 4272, observed deaths 29 277). The greatest difference was observed among younger patients and those who died from cardiovascular disease. Relative survival was also consistently lower in female patients, with adjusted excess mortality 11% higher (95% confidence interval 8% to 13%). Average years of life lost was 3.6 years (95% confidence interval 3.6 to 3.7) greater in female patients with kidney failure compared with male patients across all ages. No major differences were found in mortality by sex for haemodialysis or peritoneal dialysis. Kidney transplantation reduced but did not entirely remove the sex difference in excess mortality, with similar relative survival (P=0.83) and years of life lost difference reduced to 2.3 years (95% confidence interval 2.2 to 2.3) between female and male patients. <h3>Conclusions</h3> Compared with the general population, female patients had greater excess deaths, worse relative survival, and more years of life lost than male patients, however kidney transplantation reduced these differences. Future research should investigate whether systematic differences exist in access to care and possible strategies to mitigate excess mortality among female patients.

Wearable and implantable artificial kidney devices for end-stage kidney disease treatment: Current status and review.

Chronic kidney disease (CKD) is a major cause of early death worldwide. By 2030, 14.5 million people will have end-stage kidney disease (ESKD, or CKD stage 5), yet only 5.4 million will receive kidney replacement therapy (KRT) due to economic, social, and political factors. Even for those who are offered KRT by various means of dialysis, the life expectancy remains far too low. Researchers from different fields of artificial organs collaborate to overcome the challenges of creating products such as Wearable and/or Implantable Artificial Kidneys capable of providing long-term effective physiologic kidney functions such as removal of uremic toxins, electrolyte homeostasis, and fluid regulation. A focus should be to develop easily accessible, safe, and inexpensive KRT options that enable a good quality of life and will also be available for patients in less-developed regions of the world. Hence, it is required to discuss some of the limits and burdens of transplantation and different techniques of dialysis, including those performed at home. Furthermore, hurdles must be considered and overcome to develop wearable and implantable artificial kidney devices that can help to improve the quality of life and life expectancy of patients with CKD.

COVID-19 vaccine effectiveness in patients with non–dialysis-dependent chronic kidney diseases: findings from a population-based observational study from British Columbia, Canada

Patients with chronic kidney disease (CKD) are considered to be a high-risk group for contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) infection and postinfection complications. Recent research investigating the COVID-19 vaccine effectiveness (VE) in a population with CKD mostly involved patients receiving kidney replacement therapy, including kidney dialysis or transplantation.1–5 Little is known about the VE in non–dialysis-dependent patients with CKD.

Kidney replacement therapy in neonates: utilization trends and outcomes.

We aimed to assess prevalence and clinical characteristics of newborns receiving kidney replacement therapy (KRT). We used the National Inpatient Sample (NIS) dataset for the years 2000-2017. Newborns treated with peritoneal dialysis (PD), hemodialysis (HD), and continuous KRT (CKRT) were included. Trend analysis using the Cochran-Armitage test was used to assess prevalence over the years. A total of 64,532,552 hospitalized newborns were included. Among the 4281 infants treated with KRT, 2501 (58.4%) were treated with PD, 997 (23.3%) had HD, and 783 (18.3%) used CKRT. Associated diagnoses included congenital kidney anomalies (37.4% vs. 15% vs. 9.5%), urinary tract anomalies (35% vs. 12.5% vs. 6.3%), and congenital heart disease (68% vs. 25.7% vs. 72.3%). Median length of stay was longest in PD patients (39days vs. 18days vs. 26days), respectively. However, cost of hospitalization was greatest in CKRT patients (US $490,916 vs. US $218,514 vs. US $621,554), respectively. In the entire cohort, 54,424 newborns had acute kidney injury (AKI); of them 16,999 (31%) died. KRT was used in 2,688 (4.9%) of infants with AKI. Over the study period, trends for utilization of PD (from 0.042 to 0.06%) and CKRT (from 0.03 to 0.21%) increased whereas the hemodialysis trend decreased (from 0.021 to 0.013%). Congenital heart disease(CHD) and congenital anomalies of the kidneys and urinary tract (CAKUT) are the major diagnoses in newborns receiving KRT. Utilization of PD was greater than HD and CKRT. Trends of PD and CKRT utilization increased over time. Less than 5% of infants diagnosed with AKI received KRT.

Drugs in Clinical Development to Treat Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive cyst formation that ultimately leads to kidney failure in most patients. Approximately 10% of patients who receive kidney replacement therapy suffer from ADPKD. To date, a vasopressin V2 receptor antagonist (V2RA) is the only drug that has been proven to attenuate disease progression. However, aquaresis-related adverse events limit its widespread use. Data on the renoprotective effects of somatostatin analogues differ largely between studies and medications. This review discusses new drugs that are investigated in clinical trials to treat ADPKD, such as cystic fibrosis transmembrane conductance regulator (CFTR) modulators and micro RNA inhibitors, and drugs already marketed for other indications that are being investigated for off-label use in ADPKD, such as metformin. In addition, potential methods to improve the tolerability of V2RAs are discussed, as well as methods to select patients with (likely) rapid disease progression and issues regarding the translation of preclinical data into clinical practice. Since ADPKD is a complex disease with a high degree of interindividual heterogeneity, and the mechanisms involved in cyst growth also have important functions in various physiological processes, it may prove difficult to develop drugs that target cyst growth without causing major adverse events. This is especially important since long-standing treatment is necessary in this chronic disease. This review therefore also discusses approaches to targeted therapy to minimize systemic side effects. Hopefully, these developments will advance the treatment of ADPKD.

Survival analysis among pediatric patients receiving kidney replacement therapy: a Japanese nationwide cohort study.

Limited data are available on the survival and causes of death in pediatric patients with chronic kidney disease (CKD) stage 5 receiving kidney replacement therapy (KRT) in Asia. Data were obtained from the Japanese nationwide cross-sectional CKD stage 5 survey on pediatric patients (<20 years of age) who started KRT from 2006 to 2013. The cohort was divided into three groups according to age at the start of KRT: <1, 1-5, and 6-19 years. Among the 701 children who were included, 59.3% were boys. Peritoneal dialysis was the most common initial modality of KRT (60.3%). Median age at KRT initiation was 10.2 years. Infants (<1 year old) accounted for 16.0% of the total cohort. Overall survival at 1 and 5 years was 97.2% and 92.5%, respectively. Infants had significantly lower survival rates than the other groups (hazard ratio, 5.35; 95% CI, 2.60-11.03; P < 0.001). In contrast, after the age of 1 year, the survival rate improved and did not differ from that of other age groups. The most common causes of death were infection (35.9%) and sudden death (15.4%). The overall survival rate of pediatric patients with CKD stage 5 in Japan is like that in other high-income countries. Age at initiation of KRT is an important factor affecting survival since the poorest survival rate was observed in infants. Further improvement in infant dialysis therapy is still needed to improve survival of the youngest children. A higher resolution version of the Graphical abstract is available as Supplementary information.

Insomnia and Poor Sleep in CKD: A Systematic Review and Meta-analysis

Rationale & ObjectivePoor sleep quality and insomnia are pervasive among patients with advanced chronic kidney disease (CKD); however, these health issues have not been systematically evaluated.Study DesignSystematic review and meta-analysis.Setting & Study PopulationsAdult patients with CKD not receiving kidney replacement therapy (KRT), as well as adults receiving KRT, including hemodialysis, peritoneal dialysis, and kidney transplantation.Selection Criteria for StudiesA systematic literature search using PubMed, Embase, and PsycNET, was conducted for articles published between January 1, 1990, and September 28, 2018.Data ExtractionData on the prevalences of poor sleep quality and insomnia in patients with CKD, including those receiving and not receiving KRT, were extracted.Analytical ApproachPooled prevalences were estimated using a random-effects meta-analysis and were stratified according to age, CKD stage, World Health Organization region, risk of bias, Pittsburgh Sleep Quality Index score, and the different criteria for insomnia that were used at diagnosis.ResultsOf 3,708 articles, 93 were selected, and significant methodological heterogeneity was present. The pooled prevalences of poor sleep quality for CKD without KRT, hemodialysis, peritoneal dialysis, and kidney transplantation were 59% (95% CI, 44%-73%), 68% (95% CI, 64%-73%), 67% (95% CI, 44%-86%), and 46% (95% CI, 34%-59%), respectively. The corresponding prevalences of insomnia were 48% (95% CI, 30%-67%), 46% (95% CI, 39%-54%), 61% (95% CI, 41%-79%), and 26% (95% CI, 9%-49%), respectively. Insomnia was significantly more prevalent among patients aged 51-60 years and those aged >60 years than among those aged <50 years. The prevalence of insomnia in the European region was the lowest of all World Health Organization regions.LimitationsHigh interstudy heterogeneity.ConclusionsApproximately half of the patients with advanced CKD had poor sleep quality or insomnia, and the prevalence was even higher among those who received KRT. Kidney transplantation may reduce the burden of poor sleep quality and insomnia.

Antibody responses to 2 doses of mRNA COVID-19 vaccine in pediatric patients with kidney diseases

Antibody responses to 2 doses of mRNA COVID-19 vaccine in pediatric patients with kidney diseases

POS-161 Trends in labour and delivery outcomes among mothers receiving kidney replacement therapy: analysis of linked ANZDATA Registry and Perinatal datasets over 22 years

Delivery outcomes for women receiving kidney replacement therapy (KRT; chronic dialysis or kidney transplantation) are under-researched. Further to our previous studies of birth rates and pregnancy outcomes, we investigated labour, delivery and birth outcomes for transplanted and dialysed women, compared to births before-KRT, and non-KRT cohorts.

The leptin/adiponectin ratio as prognostic marker for dyslipidemia during 1 year of follow-up in pediatric patients receiving kidney replacement therapy.

Background: leptin and adiponectin are associated with cardiovascular disease in chronic kidney disease (CKD) patients and could be useful prognostic factors. Objectives. to explore the usefulness of the leptin/adiponectin ratio (LAR) to predict the presence or worsening of dyslipidemia during 1 year of follow-up in children receiving kidney replacement therapy (KRT). Material and methods: a prospective cohort study was performed. Pediatric KRT patients aged between 8 and 17 years who were undergoing hemodialysis or peritoneal dialysis were included. At enrollment, the lipid profile, adiponectin and leptin levels, and somatometric measurements, including body fat percentage, were determined. At the one-year follow-up, the lipid profile was reassessed. Results: of the 70 patients included, the median age was 13 years, and there was no sex predominance (52.8 % males). At the end of follow-up, the patients were divided into three groups: those without dyslipidemia (WOD), those who developed or experienced worsening of their dyslipidemia (DWD) and those with persistent dyslipidemia (PD). A LAR > 0.85 (OR, 16.7) and body fat percentage (OR, 1.46) were associated with an increased risk of PD and DWD at 12 months, independently of urea level, BMI Z-score, benzafibrate treatment, CKD progression time, and replacement treatment. Conclusions: a LAR > 0.85 and fat body percentage at the beginning of follow-up were strongly associated with the presence, persistence or worsening of dyslipidemia at the 12-month follow-up in children with KRT.

Barriers to Dialysis Home Therapy Utilization: A Systematic Review

Barriers to the utilization of home therapy among patients with chronic kidney disease (CKD) impact progression to kidney failure and access to treatment options. The impact of health disparities on home therapy utilization receiving kidney replacement therapy requires investigation. A systematic review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted to examine health disparity barriers to home therapy utilization among patients with kidney failure. Twelve articles published from 2010-2020 identified relationships between health disparities and home dialysis utilization among adults receiving kidney replacement therapy. Findings included association between the utilization of home therapy and the barriers of race/ethnicity (n = 5), economic barriers (n = 4), and insurance type (n = 3). Implications of findings are provided.

Pregnancy and delivery in women treated with renal replacement therapy: A literature review

Abstract. The problem of pregnancy and delivery in women with end-stage kidney disease is becoming increasingly important, and the number of such women who are pregnant, receiving kidney replacement therapy, is growing every year. Improvements in dialysis therapy have led to improved obstetric and perinatal outcomes, but the risk of various obstetric and perinatal complications remains extremely high. In this review, we analyzed recently published data on management and outcomes of pregnancy in women with end-stage kidney disease receiving dialysis.

Kidney Replacement Therapy for Patients Requiring Cardiopulmonary Bypass Support during Cardiac Surgery.

Kidney Replacement Therapy for Patients Requiring Cardiopulmonary Bypass Support during Cardiac Surgery.

Sex differences in mortality among binational cohort of people with chronic kidney disease: population based data linkage study

ObjectiveTo evaluate sex differences in mortality among people with kidney failure compared with the general population.DesignPopulation based cohort study using data linkage.SettingThe Australian and New Zealand Dialysis and Transplant Registry...

Nephrologists’ Perspectives on Gender Disparities in CKD and Dialysis

IntroductionGlobally, there are more women with chronic kidney disease (CKD), yet they comprise only 40% of patients receiving kidney replacement therapy by dialysis. We aimed to describe the perspectives of nephrologists on gender disparities in access to care and outcomes in CKD and dialysis.MethodsWe conducted semistructured interviews with 51 nephrologists (28, 55% women) from 22 countries from October 2019 to April 2020. Transcripts were analyzed thematically.ResultsWe identified 6 themes. Related to women were primary commitment to caregiving (with subthemes of coordinating care, taking charge of health management, deprioritizing own health, centrality of family in decision-making); vigilance and self-reliance (diligence and conscientiousness, stoicism and tolerating symptoms, avoiding burden on family, isolation and coping alone); and stereotyping, stigma, and judgment (body image, dismissed as anxiety, shame and embarrassment, weakness and frailty). Related to men was protecting masculinity (safeguarding the provider role, clinging to control, self-regard, and entitled). Decisional power and ownership included men’s dominance in decision-making and women’s analytical approach in treatment decisions. Inequities compounded by social disadvantage (financial and transport barriers, without social security, limited literacy, entrenched discrimination, vulnerability) were barriers to care for women, particularly in socioeconomically disadvantaged communities.ConclusionNephrologists perceived that women with CKD faced many challenges in accessing care related to social norms and roles of caregiving responsibilities, disempowerment, lack of support, stereotyping by clinicians, and entrenched social and economic disadvantage. Addressing power differences, challenging systemic patriarchy, and managing unconscious bias may help to improve equitable care and outcomes for all people with CKD.

Incidence of Kidney Replacement Therapy and Subsequent Outcomes Among Patients With Systemic Lupus Erythematosus: Findings From the ERA Registry

There is a dearth of data characterizing patients receiving kidney replacement therapy (KRT) for kidney failure due to systemic lupus erythematosus (SLE) and their clinical outcomes. The aim of this study was to describe trends in incidence and prevalence of KRT among these patients as well as to compare their outcomes versus those of patients treated with KRT for diseases other than SLE. Retrospective cohort study based on kidney registry data. Patients recorded in 14 registries of patients receiving KRT that provided data to the European Renal Association Registry between 1992 and2016. SLE as cause of kidney failure. Incidence and prevalence of KRT, patient survival while receiving KRT, patient and graft survival after kidney transplant, and specific causes of death. Kaplan-Meier methods and Cox regression models were fit to compare patient survival between the SLE and non-SLE groups, overall KRT, dialysis, and patient and graft survival after kidney transplant. In total, 1,826 patients commenced KRT for kidney failure due to SLE, representing an incidence of 0.80 per million population (pmp) per year. The incidence remained stable during the study period (annual percent change, 0.1% [95% CI,-0.6% to 0.8%]). Patient survival among patients with SLE receiving KRT was similar to survival in the comparator group (hazard ratio [HR], 1.11 [95% CI, 0.99-1.23]). After kidney transplant, the risk of death was greater among patients with SLE than among patients in the comparator group (HR, 1.25 [95% CI, 1.02-1.53]), whereas the risk of all-cause graft failure was similar (HR, 1.09 [95% CI, 0.95-1.27]). Ten-year patient overall survival during KRT and patient and graft survival after kidney transplant improved over the study period (HRs of 0.71 [95% CI, 0.56-0.91], 0.43 [95% CI, 0.27-0.69], and 0.60 [95% CI, 0.43-0.84], respectively). Patients with SLE receiving KRT were significantly more likely to die of infections (24.8%) than patients in the comparator group (16.9%; P< 0.001). No data were available on extrarenal manifestations of SLE, drug treatments, comorbidities, kidney transplant characteristics, or relapses of SLE. The prognosis of patients with SLE receiving KRT has improved over time. Survival of patients with SLE who required KRT was similar compared with patients who required KRT for other causes of kidney failure. Survival following kidney transplants was worse among patients with SLE.

Survey of U.S. Critical Care Practitioners on Net Ultrafiltration Prescription and Practice among Critically Ill Patients Receiving Kidney Replacement Therapy.

IntroductionThe current prescription and practice of net ultrafiltration among critically ill patients receiving kidney replacement therapy in the U.S. are unclear.Aim of the studyTo assess the attitudes of U.S. critical care practitioners on net ultrafiltration (UFNET) prescription and practice among critically ill patients with acute kidney injury treated with kidney replacement therapy.MethodsA secondary analysis was conducted of a multinational survey of intensivists, nephrologists, advanced practice providers, and ICU and dialysis nurses practising in the U.S.ResultsOf 1,569 respondents, 465 (29.6%) practitioners were from the U.S. Mainly were nurses and advanced practice providers (58%) and intensivists (38.2%). The median duration of practice was 8.7 (IQR, 4.2-19.4) years. Practitioners reported using continuous kidney replacement therapy (as the first modality in 60% (IQR 20%-90%) for UFNET. It was found that there was a significant variation in assessment of prescribed-to-delivered dose of UFNET, use of continuous kidney replacement therapy for UFNET, methods used to achieve UFNET, and assessment of net fluid balance during continuous kidney replacement therapy. There was also variation in interventions performed for managing hemodynamic instability, perceived barriers to UFNET, belief that early and protocol-based fluid removal is beneficial, and willingness to enroll patients in a clinical trial.ConclusionsThere was considerable practice variation in UFNET among critical care practitioners in the U.S., reflecting the need to generate evidence-based practice guidelines for UFNET.

Work status and work ability of patients receiving kidney replacement therapy: results from a European survey.

ABSTRACTBackgroundEmployment is important for the quality of life and financial security of patients of working age receiving kidney replacement therapy (KRT). We aimed to examine self-reported work status and general, physical and mental work ability and to determine associations between demographic, disease-related, work-related and macroeconomic factors and employment. MethodsEuropeans from 37 countries, ages 19–65 years, treated with dialysis or kidney transplantation, filled out the web-based or paper-based cross-sectional EDITH kidney patient survey between November 2017 and January 2019. We performed descriptive analyses and multivariable generalized logistic mixed models.ResultsOf the 3544 patients, 36.5% were employed and working [25.8% of dialysis patients, 53.9% of kidney transplant recipients (KTRs)]. The mean general work ability was 5.5 out of 10 (dialysis: 4.8, KTRs: 6.5). Non-working patients (all: 4.1, dialysis: 3.9, KTRs: 4.7) scored lower than working patients (all: 7.7, dialysis 7.3, KTRs: 8.0). Working dialysis patients scored lower on physical and mental work ability (7.1 and 8.1) than working KTRs (8.0 and 8.4; P < 0.001). Impaired physical work ability (42.7%) was more prevalent than impaired mental work ability (26.7%). Male sex, age 40–49 years, higher education, home dialysis or kidney transplantation as current treatment, treatment history including kidney transplantation, absence of diabetes mellitus, better general work ability and higher country gross domestic product were positively associated with employment (P < 0.05).ConclusionsLow employment rates and impaired work ability were prevalent among European patients receiving KRT. Demographic, disease-related, work-related and macro-economic factors were associated with employment.

The Latin American Dialysis and Renal Transplantation Registry: report 2019.

ABSTRACTBackgroundChronic kidney disease (CKD) in Latin America (LA) continues to represent a challenge due to the burden of disease it causes and the difficulty in accessing treatment. LA has a total population of 652 million people living in 20 countries that occupy an area of 19.2 million km2. The Latin American Dialysis and Renal Transplantation Registry (LADRTR), founded in 1991, has collected data and reports on patients receiving kidney replacement therapy (KRT) since 1993. This article summarizes the registry data for 2019.MethodsParticipating countries complete an annual survey collecting aggregated data on incident and prevalent patients on KRT in all modalities. The different treatment modalities considered were hemodialysis (HD), peritoneal dialysis (PD) and living functioning kidney graft (LFG). National gross domestic product per capita (GDP, expressed in US dollars) and life expectancy at birth (LEB) corresponding to the year 2019 were collected from the World Bank Data Bank. Prevalence and incidence were compared with previous years and were also correlated with GDP and LEB.ResultsOn 31 December 2019 a total of 432 610 patients were in KRT in LA, corresponding to an overall unadjusted prevalence of 866 per million population (pmp). Regarding treatment modality, 66.7% of the prevalent patients were treated with HD and 9.3% with PD while 24% of the patients had an LFG. A total of 85 224 patients started KRT in LA, representing a total unadjusted incidence rate of 168 pmp. Diabetic nephropathy as a cause of CKD continues to be a relevant percentage (36%) and five countries reported CKD of nontraditional causes. The kidney transplant rate in the region was 22 pmp, varying from 1 to >60 pmp. The total prevalence of KRT correlated positively with GDP per capita (r2 = 0.6, P < 0.01) and LEB (r2 = 0.23, P < 0.05). The overall incidence rate also significantly correlated with GDP (r2 = 0.307, P < 0.05). The overall unadjusted mortality rate was 13%.ConclusionAccessibility to KRT is still limited in LA. It is necessary to continue the efforts made by each country and the Latin American Society of Nephrology and Hypertension to guarantee equal access to treatment.