Society Of Nephrology Research Articles

Sustainability and dialysis: the 4 main points for a green dialysis

Dialysis represents a big challenge for the environmental sustainability, because it is bound to high consumption of water and electricity, hazardous waste incineration and subsequent greenhouse gas emissions. In recent years, it has been recognized the urgent need to preserve our environment together with the people’s health, starting from making dialysis greener. This awareness has led to a new paradigm in the history of dialysis, the concept of Green Nephrology. The Italian Society of Nephrology published 10 affordable actions in the Position Statement with the aims to increase awareness, propose joint actions and coordinate industrial/social interactions. Starting from these, there are four key points to pave the way for environmental sustainability: 1) Sustainable technologies (i.e., machines, filters, water treatment systems, acid concentrates, lighter materials, electronic patient record); 2) Green dialysis centers; 3) Environmental improvement project, using tools to define targets and their monitoring; 4) Nurse role, as he is the main environmental sustainability promoter. To achieve Green Nephrology it’s necessary a partnership between all the stakeholders of the healthcare system. Since the growing awareness of the problem and the existence of ways to solve it, it’s time to act and the effective way to do it is to implement all the solutions provided in this article in an immediate future.

Clinicians' priorities for exercise programming for people receiving peritoneal dialysis: Qualitative content analysis from an international survey.

Exercise and physical activity have been shown to improve health outcomes among people receiving peritoneal dialysis (PD), however, little is known about PD clinicians' perceptions and practices regarding exercise counselling. To inform exercise program design and implementation, we distributed a cross-sectional online questionnaire to PD clinicians between July and December 2021 through professional nephrology societies and networks. As part of this survey, participants were asked, "What are the most important aspects you would like to see incorporated in an exercise program for PD patients?" Six hundred and nine respondents provided 1249 unique perspectives. Responses were coded using summative content analysis and grouped into themes. The overarching theme identified was the need for individualized and accessible programming. Under this umbrella, the four main sub-themes identified were: promotion of specific exercises, overcoming common barriers to exercise, perceived cornerstones of exercise prescriptions, and program design to address patient-relevant outcomes. Overall, PD clinicians believed that PD does not preclude exercise participation and recognized the potential for exercise to improve physical, mental, and social well-being. The involvement of exercise professionals was valued in PD clinical programs. However, additional education for practitioners and patients regarding safety and the benefits of exercise is required to assist in widespread implementation and acceptance of exercise programming in the PD population.

Does the standard proteinuria cut-off for renal biopsy in lupus nephritis as per the current guidelines hold good for Asian population? A single-centre study from South India.

Current rheumatology and nephrology society guidelines in lupus nephritis do not recommend renal biopsy for proteinuria of less than 500mg/24h. This might lead to a significant delay in the early diagnosis of lupus nephritis. The main aim of this study is to determine the nature of renal lesions in patients with low-grade proteinuria and to analyze the predictors for clinically significant lupus nephritis. This was a single-center, retrospective study. All consecutive patients of lupus nephritis, with low-grade proteinuria (200mg to 500mg/24h) undergoing renal biopsy were enrolled in this study. The renal biopsies were classified into significant lesions (Class III/IV/V) and non-significant lesions (Class I and II). Treatment naïve groups and treatment-modified groups were analyzed separately. Predictive factors for significant renal lesions were determined by univariate and multivariate analysis. We identified 183 patients of lupus with proteinuria between 200 and 500mg / 24h. Mean (SD) age was 30.2 (11.39) years with 167 (91.2%) of them being females. The mean (SD) baseline proteinuria was 351.03 (98.1) mg/24h 85 patients (46.5%) had proliferative lupus nephritis where whereas 17 patients (9.3%) had membranous nephropathy. Crescents and fibrinoid necrosis were seen in 10 (5.46%) and 24 (13.11 %) patients respectively. Isolated proteinuria without any other sediments was seen in 95 patients (51.9%) of which 29 patients had proliferative lupus nephritis. Elevated Anti-double stranded DNA (anti-dsDNA), low C3, low C4 and the presence of urinary sediments were significantly associated with significant renal lesions in biopsy. Significant renal lesions were seen in around half of the patients with low-grade proteinuria underscoring the importance of performing a renal biopsy in this set of patients. Low C3 and C4, urinary sediments, and elevated anti-dsDNA were predictors for significant renal lesions.

A-201 The Impact of Implementing the CKD-EPI 2021 Equation for Calculation of Estimated Glomerular Filtration Rate (eGFR) and the Kidney Failure Risk Equation (KFRE) on a Large Community Laboratory Population

Abstract Background Community laboratories in Ontario, Canada have reported estimated glomerular filtration rate (eGFR) using the CKD-EPI 2009 equation without race adjustment since 2020. In 2023, the Canadian Society of Nephrology recommended implementation of the CKD-EPI 2021 equation for eGFR, which does not incorporate a race-based modifier. Community laboratories will also report the 5-year Kidney Failure Risk Equation (KFRE), a risk prediction model to estimate the risk of renal failure in people with chronic kidney disease (CKD) Stages 3 to 5 (eGFR <60 mL/min/1.73m2), which is more accurate than judging by eGFR alone. This study assessed the impact of implementing the CKD-EPI 2021 equation for eGFR and the 5-year KFRE in a large community laboratory population. Methods Laboratory results for serum creatinine and urine albumin to creatinine ratio (ACR), patient sex and age were extracted from Dynacare’s laboratory information system for November 2023. The CKD-EPI 2009 without race adjustment and the CKD-EPI 2021 were calculated. Reclassification of CKD stage using the CKD-EPI 2021 equation was assessed. The 4-variable 5-year KFRE was calculated for patients in CKD Stage 3-5 (eGFR <60 mL/min/1.73m2) when all parameters including, patient age, sex, creatinine and ACR, were available. Results Data was extracted for 242,843 patients. The median age was 61 years old and 47% of the population was female. The calculated median eGFR was 83 and 87 mL/min/1.73m2 when the CKD-EPI 2009 with no race adjustment, and CKD-EPI 2021 equation, respectively, were applied. Linear regression analysis showed a correlation of 0.997 with a slope of 0.990 and y-intercept of 4.513. A total of 13.0% (n=31,679) of patients were reclassified into a less progressive CKD stage when the CKD-EPI 2021 was applied compared to the CKD-EPI 2009 without race adjustment. Notable, was the reclassification of 21.8% (n=6899) of those patients from Stage 3a to 2, i.e. patients no longer have CKD (eGFR >60 mL/min/1.73m2) based on the new calculation. 64.8% (n=20513) of patients were reclassified from Stage 2 to 1, 9.4% (n=2977) were reclassified from Stage 3b to 3a, 3.5% (n=1102) were classified from Stage 4 to 3b, and 0.6% (n=188) were reclassified from Stage 5 to 4. The 5-year KFRE was calculated when creatinine and ACR were included on the same order and the patient was classified as Stage 3 to 5 (n=12,737 patients with eGFR <60 mL/min/1.73m2). The 5-year KFRE showed increasing median risk, 1%, 4%, 27%, 95%, as CKD stage increased from 3a, 3b, 4 and 5, respectively. 1.1% (n=58) of patients in Stage 3a, 43.3% (n=1584) of patients in Stage 3b, 96.6% (n=1994) of patients in Stage 4, and 100% (n=401) of patients in Stage 5 met the KFRE threshold of ≥5% for referral to nephrology. Conclusions Implementation of the CKD-EPI 2021 resulted in reclassification to a less progressive CKD stage. Use of the KFRE as a clinical decision tool will increase patient referral to nephrology. This study provided insight into the impact of the implementation of the CKD-EPI 2021 and KFRE and highlights the underutilization of ACR in a community population.

A-113 Evaluation of Cystatin C Ordering Trends in a Quaternary Care Health System

Abstract Background Cystatin C is an alternative and adjunct kidney biomarker to creatinine in the estimation of glomerular filtration rate (eGFR). The National Kidney Foundation and American Society of Nephrology have called for increased use of cystatin C in the evaluation of kidney function. Our institution brought cystatin C testing in-house in August 2021. The goal of this study was to evaluate the utilization and longitudinal ordering trends of cystatin C within our quaternary care health system. Methods Cystatin C is measured on a Roche cobas® c502 using an assay traceable to IFCC-certified reference material. The electronic health record system (Epic) was queried using Epic SlicerDicer to identify ordering trends within our academic medical center between July 2021 and January 2024. The frequency of unique (one-time) cystatin C orders and concomitant orders with creatinine was also conducted. An in-depth analysis and chart review was performed over a one-month period to evaluate ordering locations, underlying clinical conditions, including previous diagnosis of kidney disease, and correlations between cystatin C and creatinine measurements. Results Between July 2021 and January 2024, 11,577 tests were performed from 8,415 unique patients. Cystatin C orders remained stable since April 2022, with an average 370 orders (363-378) per month. Eighty percent of cystatin C test requests were accompanied with creatinine testing during the same encounter. In a detailed analysis of a one month period, cystatin C testing was primarily performed in patients with an existing diagnosis of kidney disease (66%) and in the evaluation of renal function in patients with a cancer diagnosis (23%). Conclusions There has been sustained adoption of cystatin C by providers at our institution. The majority of orders have occurred in patients with an underlying renal diagnosis, as well as comorbid or chronic conditions that may affect kidney function.

Management of heart disease in renal transplant recipients: a national Delphi survey-based SET/SEC/SEN consensus document

Renal transplantation improves the survival and quality of life of patients with end-stage renal disease. Cardiovascular disease is the leading cause of morbidity and mortality in renal transplant recipients. The bidirectional relationship between renal and heart disease creates a unique clinical scenario that demands a comprehensive and personalized approach. This expert consensus, drafted by the Spanish Society of Transplantation, the Spanish Society of Cardiology, and the Spanish Society of Nephrology, aims to assess current practices and propose strategies for the management of heart disease in renal transplant recipients. A panel of Spanish nephrologists and cardiologists with expertise in renal and heart transplantation reviewed the scientific evidence concerning the current management of heart disease in renal transplant recipients. Subsequently, consensus statements were created through a 2-round Delphi methodology, resulting in 30 statements covering key topics such as the identification of renal transplant candidates, the management of heart disease in renal transplant recipients, and eligibility for combined heart-kidney transplantation in patients with both end-stage renal disease and cardiac disease. These consensus statements provide expert guidance for the management of heart disease in renal transplant recipients, an area where published clinical evidence remains limited.

ChatGPT Solving Complex Kidney Transplant Cases: A Comparative Study With Human Respondents.

ChatGPT has shown the ability to answer clinical questions in general medicine but may be constrained by the specialized nature of kidney transplantation. Thus, it is important to explore how ChatGPT can be used in kidney transplantation and how its knowledge compares to human respondents. We prompted ChatGPT versions 3.5, 4, and 4 Visual (4V) with 12 multiple-choice questions related to six kidney transplant cases from 2013 to 2015 American Society of Nephrology (ASN) fellowship program quizzes. We compared the performance of ChatGPT with US nephrology fellowship program directors, nephrology fellows, and the audience of the ASN's annual Kidney Week meeting. Overall, ChatGPT 4V correctly answered 10 out of 12 questions, showing a performance level comparable to nephrology fellows (group majority correctly answered 9 of 12 questions) and training program directors (11 of 12). This surpassed ChatGPT 4 (7 of 12 correct) and 3.5 (5 of 12). All three ChatGPT versions failed to correctly answer questions where the consensus among human respondents was low. Each iterative version of ChatGPT performed better than the prior version, with version 4V achieving performance on par with nephrology fellows and training program directors. While it shows promise in understanding and answering kidney transplantation questions, ChatGPT should be seen as a complementary tool to human expertise rather than a replacement.

Executive summary of the Spanish consensus for the diagnosis, management, and follow-up of primary hyperaldosteronism.

Primary hyperaldosteronism (PH) is the most common cause of secondary hypertension (HTN) and is associated with a higher cardiometabolic risk than essential HTN. Nevertheless, PH remains clearly underdiagnosed. An early diagnosis and adequate treatment of this disease are essential to reduce the cardiometabolic morbimortality associated with aldosterone excess. PH follow-up is equally essential; however, there is little consensus on how it should be performed, being a topic rarely mentioned by the different clinical practice guidelines. The aim of this executive summary is to summarize the recommendations made in the Spanish consensus of PH for the diagnosis, management, and follow-up of these patients. The Spanish consensus was reached from a multidisciplinary perspective through a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), the Spanish Society of Cardiology (SEC), the Spanish Society of Nephrology (SEN), the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Radiology (SERAM), the Spanish Society of Vascular and Interventional Radiology (SERVEI), the Spanish Society of Laboratory Medicine (SEQC(ML)), the Spanish Society of Anatomic-Pathology (EAP), and the Spanish Association of Surgeons (AEC).

KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease in Children and Adults: a commentary from the European Renal Best Practice (ERBP)

ABSTRACT The Kidney Disease: Improving Global Outcomes (KDIGO) 2024 Guideline for Identification and Management of Chronic Kidney Disease (CKD) is a welcome development, coming 12 years after the paradigm-changing 2012 guidelines. We are living in an unprecedented era in nephrology with novel therapies, including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists, now being proven in multiple randomized controlled clinical trials to reduce both the progression of CKD and cardiovascular morbidity and mortality. The KDIGO 2024 CKD Guideline is aimed at a broad audience looking after children and adults with CKD and provide practical and actionable steps to improve care. This commentary reviews the guideline sections pertaining to the evaluation and risk assessment of individuals with CKD from a European perspective. We feel that despite the last guideline being published 12 years ago, and the fact that the assessment of CKD has been emphasized by many other national/international nephrology, cardiology and diabetology guidelines and societies, the diagnosis and treatment of CKD remains poor across Europe. As such, the KDIGO 2024 CKD Guideline should be seen as an urgent call to action to improve diagnosis and care of children and adults with CKD across Europe. We know what we need to do. We now need to get on and do it.

Nutritional assessment and medical dietary therapy for management of obesity in patients with non-dialysis chronic kidney disease: a practical guide for endocrinologist, nutritionists and nephrologists. A consensus statement from the Italian society of endocrinology (SIE), working group of the club nutrition-hormones and metabolism; the Italian society of nutraceuticals (SINut), club ketodiets and nutraceuticals "KetoNut-SINut"; and the Italian society of nephrology

Chronic kidney disease (CKD) is a serious health concern with an estimated prevalence of about 13.4% worldwide. It is cause and consequence of various comorbidities, including cardiovascular diseases. In parallel, common pathological conditions closely related to ageing and unhealthy dietary habits increase the risk of CKD development and progression, including type 2 diabetes and obesity. Among these, obesity is either independent risk factor for new onset kidney disease or accelerates the rate of decline of kidney function by multiple mechanisms. Therefore, the role of diets aimed at attaining weight loss in patients with obesity is clearly essential to prevent CKD as to slow disease progression. Various dietary approaches have been licensed for the medical dietary therapy in CKD, including low-protein diet and Mediterranean diet. Interestingly, emerging evidence also support the use of low-carbohydrate/ketogenic diet (LCD/KD) in these patients. More specifically, LCD/KDs may efficiently promote weight loss, improve metabolic parameters, and reduce inflammation and oxidative stress, resulting in a dietary strategy that act globally in managing collateral conditions that are directly and indirectly related to the kidney function. This consensus statement from the Italian Society of Endocrinology (SIE), working group of the Club Nutrition - Hormones and Metabolism; the Italian Society of Nutraceuticals (SINut), Club Ketodiets and Nutraceuticals "KetoNut-SINut"; and the Italian Society of Nephrology (SIN) is intended to be a guide for Endocrinologist, Nutritionists and Nephrologist who deal with the management of patients with obesity with non-dialysis CKD providing a practical guidance on assessing nutritional status and prescribing the optimal diet in order to best manage obesity to prevent CKD and its progression to dialysis.

Assessment of iron metabolism and iron deficiency in incident patients on incident continuous ambulatory peritoneal dialysis.

The aim of this study was to investigate iron status and iron deficiency in incident continuous ambulatory peritoneal dialysis (CAPD) patients and identify influencing factors. Patients with end-stage renal disease were enrolled. Clinical data of iron metabolism and biochemical and dialysis parameters during the first peritoneal dialysis evaluation were collected. Serum ferritin (SF) and transferrin saturation (TSAT) levels were evaluated, and independent influencing factors were identified by correlation and regression analyses. Of 1,128 adult CAPD patients, 41.2% had iron deficiency (ID), 15.7% had absolute iron deficiency, and 8.2% had functional iron deficiency. The average SF level was (276.8 ± 277.9) μg/L, and iron saturation was (29.8 ± 12.7)%. Additionally, 50.2 and 69.3% of patients reached targets in SF level and iron saturation recommended by the Chinese Society of Nephrology. SF level and TSAT were not correlated with estimated glomerular filtration rate, whereas negatively correlated with platelet count and inflammatory factors. Low platelet count, presence of diabetes mellitus and high interleukin 6 levels were independent factors of lower TSAT. ID is common in patients with CAPD. Women and those with thrombocytopenia, diabetes, and inflammation are at higher risk for iron storage or reduced iron utilization. In the initial CAPD stage, a reasonable iron supplement strategy may be established for CAPD patients with high-risk factors.

Impact of hemodialysis center accreditation on patient mortality: Korean nationwide cohort study.

Since hemodialysis (HD) patients are prone to various complications and high mortality, they need to be treated in HD units with professional personnel, proper equipment, and facilities. The Korean Society of Nephrology has been conducting an HD unit accreditation program since 2016. This study was performed to evaluate whether a qualified dialysis center (QDC) reduced the mortality of HD patients. This longitudinal, observational cohort study included 31,227 HD from 832 facilities. HD units were classified into two groups: the hospitals that have been certified as QDC between 2016 and 2018 (n = 219) and hospitals that have never been certified as QDC (non-QDC, n = 613). Baseline characteristics and patient mortality were compared between QDC vs. non-QDC groups using Korean HD quality assessment data from 2018. Multivariate logistic regression and the Cox proportional hazards model were used to compare patient mortality between the two groups. Among study subjects, 30.6% of patients were treated at QDC and 69.4% were treated at non-QDC. The patients in the QDC were younger and had a longer dialysis duration, lower serum phosphorus and calcium levels, and higher hemoglobin and single-pool Kt/V levels compared to the patients from the non-QDC group. After adjusting for demographic and clinical parameters, QCD independently reduced mortality risk (hazard ratio, 0.897; 95% confidence interval, 0.847-0.950; p < 0.001). The HD unit accreditation program may reduce the risk of death among patients undergoing HD.

Estimated glomerular filtration rate in clinical practice: Consensus positioning of the Brazilian Society of Nephrology (SBN) and Brazilian Society of Clinical Pathology and Laboratory Medicine (SBPC/ML)

RESUMO A doença renal crônica (DRC) representa um dos principais problemas de saúde pública da atualidade. A dosagem da creatinina sérica e a estimativa da taxa de filtração glomerular (TFG) são as principais ferramentas para avaliação da função renal. Para a estimativa da TFG, existem diversas equações, sendo a mais recomendada a CKD-EPI (Chronic Kidney Disease – Epidemiology). Existem ainda algumas controvérsias com relação à dosagem da creatinina sérica e da estimativa da TFG, uma vez que vários fatores podem interferir nesse processo. Uma importante mudança recente foi a retirada da correção por raça das equações para estimativa da TFG, que superestimavam a função renal, e consequentemente retardavam a implementação de tratamentos como diálise e transplante renal. Neste documento de consenso da Sociedade Brasileira de Nefrologia e Sociedade Brasileira de Patologia Clínica e Medicina Laboratorial são revisados os principais conceitos relacionados à avaliação da função renal, possíveis controvérsias existentes e recomendações para a estimativa da TFG na prática clínica.

Estimated glomerular filtration rate in clinical practice: Consensus positioning of the Brazilian Society of Nephrology (SBN) and Brazilian Society of Clinical Pathology and Laboratory Medicine (SBPC/ML).

Chronic kidney disease (CKD) represents one of today's main public health problems. Serum creatinine measurement and estimation of the glomerular filtration rate (GFR) are the main tools for evaluating renal function. There are several equations to estimate GFR, and CKD-EPI equation (Chronic Kidney Disease - Epidemiology) is the most recommended one. There are still some controversies regarding serum creatinine measurement and GFR estimation, since several factors can interfere in this process. An important recent change was the removal of the correction for race from the equations for estimating GFR, which overestimated kidney function, and consequently delayed the implementation of treatments such as dialysis and kidney transplantation. In this consensus document from the Brazilian Societies of Nephrology and Clinical Pathology and Laboratory Medicine, the main concepts related to the assessment of renal function are reviewed, as well as possible existing controversies and recommendations for estimating GFR in clinical practice.

Physical activity and exercise in chronic kidney disease: consensus statements from the Physical Exercise Working Group of the Italian Society of Nephrology

The Italian Society of Nephrology has tasked its Working Group on Physical Exercise with developing a consensus statement document on physical activity and exercise in patients with chronic kidney disease (CKD). This paper consists of 16 points that were discussed, and approved using the mini-Delphi method by 15 members of the working group. Each statement is based on a comprehensive review of the literature, clinical experience, and expert opinions. Overall, the statements affirm that regular physical activity and exercise training offer numerous benefits to CKD patients, including improved physical function, enhanced cardiometabolic and neuromuscular function, cognitive benefits, and an overall improvement in quality of life. Furthermore, exercise may provide nephroprotection and reduce mortality. These advantages are observed across all CKD stages, whether on conservative therapy or kidney replacement therapy (hemodialysis or peritoneal dialysis), and in kidney transplant recipients. Moreover, when physical activity and exercise training are implemented with appropriate precautions, they are safe in CKD patients. Gradual physical activity and customized exercise programs should be tailored to the patient's exercise tolerance, potentially enhancing compliance. Clinicians are encouraged to use a series of questionnaires and tests to assess the patient's level of physical activity and performance. However, exercise and physical activity are poorly implemented in clinical practice due to many barriers related to patients and healthcare staff. Overcoming these barriers requires the proactive role of the nephrologists, who should actively incorporate exercise training and promote physical activity within routine care plans. Adopting a multidisciplinary team approach, which includes nephrologists, nurses, exercise professionals, and dietitians, is crucial for providing comprehensive rehabilitation for CKD patients. Integrating new technologies and remote check ups could further enhance the effectiveness of these interventions.Graphical abstract

Investigation of current clinical practices and perceptions of patients and caregivers regarding Alport syndrome in South Korea.

Alport syndrome (AS) is a highly prevalent inherited kidney disease. Early diagnosis and intervention are crucial for improved kidney outcomes. This study evaluated awareness among Korean clinicians about AS and assessed the understanding of AS patients and caregivers. An online survey targeting registered members of the Korean Society of Nephrology, the Korean Society of Pediatric Nephrology, AS patients, and their caregivers was conducted from January to April 2023. Out of 103 respondents, most had treated fewer than 10 AS patients. For certain kidney diseases, such as chronic kidney disease of unknown origin and focal segmental glomerulosclerosis, half or fewer considered AS as a potential diagnosis. Only half preferred immediate confirmation tests for suspected AS. Genetic testing was available at half of the medical centers, and fewer than half of the adult nephrologists considered genetic testing to be essential. While all the surveyed nephrologists would prescribe renin-angiotensin system blockade, the majority hesitated to initiate treatment. Vigilant genetic testing for donor candidates was not a common practice. While 80% of patients and 50% of caregivers understood the nature and prognosis of AS, they regretted the delayed diagnoses, insufficient explanations, and the absence of support groups. Not rarely, AS patients may have been unrecognized as AS. Despite the noteworthy advancement of AS, the recent guidelines have not been widely adopted in clinical practice in Korea. Considering the challenges in Korea, there is an urgent need for locally tailored clinical practice recommendations and a dedicated registry to optimize patient outcomes.

Interventional nephrology in peritoneal dialysis: Best practice report of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology.

The procedure of peritoneal dialysis (PD) catheter placement is of utmost importance for a good outcome of peritoneal dialysis. Currently, catheters are mainly placed by surgeons and interventional nephrologists. Still, there is a lack of trained personnel in many dialysis units, which can impair the efficiency of PD units and reduce the patients' possibility to enter a PD programme. The Italian Society of Nephrology has endorsed a practical core curriculum for interventional nephrology in PD available on the Society website, which is here reported for the wider nephrology community. The topics addressed are the hernias of the abdominal wall, catheter placement with standard surgical open technique, basic video-laparoscopy, advanced video-laparoscopy, video-laparoscopic cholecystectomy and catheter placement, cuff-shaving and video-laparoscopy in catheter malfunction.

59th Annual Scientific Meeting of the Australian and New Zealand Society of Nephrology (ANZSN), 31 August-4 September 2024.

59th Annual Scientific Meeting of the Australian and New Zealand Society of Nephrology (ANZSN), 31 August-4 September 2024.

59th Annual Scientific Meeting of the Australian and New Zealand Society of Nephrology (ANZSN), 31 August-4 September 2024.

59th Annual Scientific Meeting of the Australian and New Zealand Society of Nephrology (ANZSN), 31 August-4 September 2024.

59th Annual Scientific Meeting of the Australian and New Zealand Society of Nephrology (ANZSN), 31 August-4 September 2024.

59th Annual Scientific Meeting of the Australian and New Zealand Society of Nephrology (ANZSN), 31 August-4 September 2024.