Advertisement

The Incidence and Pathophysiology of the Obesity Paradox: Should Peritoneal Dialysis and Kidney Transplant Be Offered to Patients with Obesity and End-Stage Renal Disease?

  • Ramzi Vareldzis
  • Mihran Naljayan
  • Efrain Reisin
Hypertension and Obesity (E Reisin, Section Editor)
  • 89 Downloads
Part of the following topical collections:
  1. Topical Collection on Hypertension and Obesity

Abstract

Purpose of Review

To educate nephrologists and primary-care physicians about the incidence, pathophysiology, and survival benefits of the obesity paradox in end-stage renal disease (ESRD). This review also discusses the future of kidney transplant and peritoneal dialysis in obese dialysis patients.

Recent Findings

Obesity paradox in ESRD was first reported three decades ago, and since then, there have been several epidemiological studies that confirmed the phenomenon. Regardless of the anthropometric indices used to define obesity in ESRD patients, these markers serve to predict the dialysis patient’s survival. The pathophysiology of obesity paradox tends to be multifactorial. Recent cohort studies demonstrated a survival benefit in all race and ethnic groups, but Hispanics and blacks experienced increased survival rates when compared to non-Hispanic whites. Obese dialysis patients should be offered peritoneal dialysis, especially if they are new to dialysis and have an adequate renal residual function. Several studies have shown that the benefit of receiving kidney transplant in obese patients exceeds the risks. The robotic-assisted kidney transplant (RAKT) procedure is the latest innovation that could offer hope for obese dialysis patients who have been denied or are waiting for kidney transplant.

Summary

The obesity paradox phenomenon in ESRD is a unique illustration of survival benefit in a population that has a high overall annual mortality. Peritoneal dialysis should be encouraged for obese patients who have preserved residual renal function. Kidney transplant centers should encourage RAKT utilization in obese dialysis patients instead of denying them a kidney transplant.

Keywords

Obesity paradox in ESRD Malnutrition-inflammation complex syndrome Peritoneal dialysis in obesity Robotic assisted kidney transplant 

Notes

Acknowledgments

We thank Michelle G. Holt, managing editor, LSU School of medicine, department of medicine for assisting in editing our publication.

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Saran R, Li Y, Robinson B, et al. US renal data system 2015 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2016;67(3 suppl 1):S1–S305.Google Scholar
  2. 2.
    Goodkin DA, Mapes DL, Held PJ. The dialysis outcomes and practice patterns study (DOPPS): how can we improve the care of hemodialysis patients? Semin Dial. 2001;14(3):157–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Kalantar-Zadeh K, Kovesdy CP, Streja E, et al. Transition of care from pre-dialysis prelude to renal replacement therapy: the blueprints of emerging research in advanced CKD. Nephrol Dial Transplant. 2017;32(suppl-2).Google Scholar
  4. 4.
    Kalantar-Zadeh K, Block G, Hymphreys MH, Kopple JD. Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients. Kidney Int. 2003;63:793–808.CrossRefPubMedGoogle Scholar
  5. 5.
    Leavey SF, Strawderman RL, Jones CA, Port FK, Held PJ. Simple nutritional indicators as independent predictors of mortality in hemodialysis patients. Am J Kidney Dis. 1998;31:997–1006.CrossRefPubMedGoogle Scholar
  6. 6.
    Fleischmann E, Teal N, Dudley J, May W, Bower JD, Salahudeen AK. Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients. Kidney Int. 1999;55:1560–15667.CrossRefPubMedGoogle Scholar
  7. 7.
    Kopple JD, Zhu Z, Lew NL, Lowrie EG. Body weight-for-height relationships predict mortality in maintenance hemodialysis patients. Kidney Int. 1999;56:1136–48.CrossRefPubMedGoogle Scholar
  8. 8.
    • Glanton CW, Kao TC, Cruess D, et al. Impact of renal transplantation on survival in end-stage renal disease patients with elevated body mass index. Kidney Int. 2003;63(2):647–53. Original Article: Survival advantages for kidney transplant in obese patients. CrossRefPubMedGoogle Scholar
  9. 9.
    WHO expert consultation: Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157–63.Google Scholar
  10. 10.
    Agarwal R, Bills JE, light RP et al. Diagnosing obesity by body mass index in chronic kidney disease: an explanation for the “obesity paradox?” Hypertension 2010; 56: 893–900.CrossRefPubMedGoogle Scholar
  11. 11.
    Beddhu S, Pappas LM, Ramkumar N, Samore M. Effects of body size and body composition on survival in hemodialysis patients. JASN. 2003;14(9):2366–72.CrossRefPubMedGoogle Scholar
  12. 12.
    •• Postorino M, et al. Abdominal obesity and all-cause and cardiovascular mortality in end-stage renal disease. J Am Coll Cardiol. 2009;53:1255–72. Original Study: waist circumference and Waist/Hip ratio might offer better predictor of survival than BMI alone. CrossRefGoogle Scholar
  13. 13.
    Kovesdy CP, Czira ME, Rudas A, Ujszaszi A, Rosivall L, Novak M, et al. Body mass index, waist circumference and mortality in kidney transplant recipients. Am J Transplant. 2010;10:2644–51.CrossRefPubMedGoogle Scholar
  14. 14.
    Degoulet P, Legrain M, Reach I, et al. Mortality risk factors in patients treated by chronic hemodialysis. Report of the Diaphane collaborative study. Nephron. 1982;31:103–10.CrossRefPubMedGoogle Scholar
  15. 15.
    • Leavey SF, McCullough K, Hecking E, Goodkin D, Port FK, Young EW. Body mass index and mortality in healthier as compared with sicker Haemodialysis patients: results from the Dialysis Outcomes and Practice and Patterns Study (DOPPS). Nephrol Dial Transplant. 2001;16:2386–94. Original Study: major observational study showing a survival advantages to obese patients on MHD. CrossRefPubMedGoogle Scholar
  16. 16.
    •• Glanton CW, Hypolite IO, Hshieh PB, Agodoa LY, Yuan CM, Abbott KC. Factors associated with improved short term survival in obese end stage renal disease patients. Ann Epidemiol. 2003;13(2):136–43. Original Article: historical cohort study showing obese patients have slight survival benefit. CrossRefPubMedGoogle Scholar
  17. 17.
    Ricks J, Molnar M, Kovesdy C, Kopple J, Norris K, Rajnish M, et al. Racial and ethnic differences in the association of body mass index and survival in maintenance hemodialysis patients. Am J Kidney Dis. 2011;58(4):574–82.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Wong J, Port F, Hulbert-Shearon T, et al. Survival advantage in Asian American end-stage renal disease patients. Kidney Int. 1999;55:2515–23.CrossRefPubMedGoogle Scholar
  19. 19.
    Johansen KL, Young B, Kaysen G, Chertow G. Association of body size with outcomes among patients beginning dialysis. Am J Clin Nutr. 2004;80(2):324–32.CrossRefPubMedGoogle Scholar
  20. 20.
    •• Park J, Jin DC, Molnar MZ, Dukkipati R, Kim YL, Jing J, et al. Mortality—predictability of body size and muscle mass surrogates in Asian versus Caucasian and African—American hemodialysis patients. Mayo Clin Proc. 2013;88(5):479–86. Original Article: confirmed that race does not modify obesity paradox phenomenon. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Kalantar-Zadeh K, Block G, Horwich T, Fonarow GC. Reverse epidemiology of conventional cardiovascular risk factors in patients with chronic heart failure. J Am Coll Cardiol. 2004;43:1439–44.CrossRefPubMedGoogle Scholar
  22. 22.
    Stevens J, Cai J, Pamuk ER, Williamson DF, Thun MJ, Wood JL. The effect of age on the association between body-mass index and mortality. N Engl J Med. 1998;338:1–7.CrossRefPubMedGoogle Scholar
  23. 23.
    Sparks JA, Chang SC, Nguyen US, Barbhaiya M, Tedeschi SK, Lu B, et al. Weight change during the early rheumatoid arthritis period and risk of subsequent mortality in women with rheumatoid arthritis and matched comparators. Arthritis Rheumatol. 2018;70(1):18–29.CrossRefPubMedGoogle Scholar
  24. 24.
    Chlebowski RT, Grosvenor M, Lillington L, Sayre J, Beall G. Dietary intake and counseling, weight maintenance, and the course of HIV infection. J Am Diet Assoc. 1995;95:428–32.CrossRefPubMedGoogle Scholar
  25. 25.
    Yeh S, Wu SY, Levine DM, et al. Quality of life and stimulation of weight gain after treatment with megestrol acetate: correlation between cytokine levels and nutritional status, appetite in geriatric patients with wasting syndrome. J Nutr Health Aging. 2000;4:246–51.PubMedGoogle Scholar
  26. 26.
    • Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis. 2003;42:864–81. Review Article: Discusses proposed of obesity paradox pathophysiology. CrossRefPubMedGoogle Scholar
  27. 27.
    Kopple JD. Nutritional status as a predictor of morbidity and mortality in maintenance dialysis patients.Google Scholar
  28. 28.
    Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med. 1999;340:448–54.CrossRefPubMedGoogle Scholar
  29. 29.
    Suffredini AF, Fantuzzi G, Badolata R, Oppendheim JJ, O’Grady NP. New insights into the biology of the acute phase response. J Clin Immunol. 1999;19:203–14.CrossRefPubMedGoogle Scholar
  30. 30.
    Owen WF, Lowrie EG. C-reactive protein as an outcome predictor for maintenance hemodialysis patients. Kidney Int. 1998;54:627–36.CrossRefPubMedGoogle Scholar
  31. 31.
    Yeun JY, Levine RA, Mantadilok V, Kaysen GA. C-reactive protein predicts all-cause and cardiovascular mortality in hemodialysis patients. Am J Kidney Dis. 2000;35:269–476.CrossRefGoogle Scholar
  32. 32.
    Iseki K, Tozawa M, Yoshi S, Fukyama K. Serum C-reactive protein (CRP) and risk of death in chronic dialysis patients. Nephrol Dial Transplant. 1999;14:1956–60.CrossRefPubMedGoogle Scholar
  33. 33.
    Kalantar-Zadeh K, Block G, McAllister C, Humphreys M, Kopple JD. Appetite inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients. Am J Clin Nutr. 2004;80:299–307.CrossRefPubMedGoogle Scholar
  34. 34.
    Zimmermann J, Herrlinger S, Pruy A, Metzger T, Wanner C. Inflammation enhances cardiovascular risk and mortality in hemodialysis patients. Kidney Int. 1999;55:648–58.CrossRefPubMedGoogle Scholar
  35. 35.
    Qureshi R, Alvestrand A, Divino-Filho J, Gutierrez A, Heimburger O, Lindholm B, et al. Inflammation, malnutrition, and cardiac disease as predictors of mortality in hemodialysis patients. J Am Soc Nephrol. 2002;13(Suppl):S28–36.PubMedGoogle Scholar
  36. 36.
    Kalantar-Zadeh K, Kopple JD, Humphreys MH, Block G. Comparing outcome predictability of markers of malnutrition—inflammation complex syndrome in haemodialysis patients. Nephrol Dial Transplant. 2004;19:1507–19.CrossRefPubMedGoogle Scholar
  37. 37.
    Kalantar-Zadeh K, Rhee C, Sim JJ, et al. Why cachexia kills: examining the causality of poor outcomes in wasting conditions. J Cachexia Sarcopenia Muscle. 2013;4:89–94.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Kopple JD. McCollum award lecture, 1996: protein-energy malnutrition in maintenance dialysis patients. Am J Clin Nutr. 1997;65:1544–57.CrossRefPubMedGoogle Scholar
  39. 39.
    Horwich TB, Fonarow GC, Hamilton MA, Maclellan WR, Woo MA, Tillisch JH. The relation between obesity and mortality in patients with heart failure. 2001;38:789–95.Google Scholar
  40. 40.
    McIntyre CW, Burton JO, Selby NM, Lesccisotti L, Korsheed S, Baker CS, et al. Hemodialysis-induced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow. Clin J Am Soc Nephrol. 2008;3:19–26.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Kalantar-Zadeh K, Kuwae N, Wu DY, Shantouf RS, Fouque D, Anker SD, et al. Associations of body fat and its changes over time with quality of life and prospective mortality in hemodialysis patients. Am J Clin Nutr. 2006;83:202–10.CrossRefPubMedGoogle Scholar
  42. 42.
    Rauchhaus M, Coats AJ, Anker SD. The endotoxin-lipoprotein hypothesis. 2000;356:930–3.Google Scholar
  43. 43.
    Culleton BF, Larson MG, Wilson PW, Evans JC, Parfrey PS, Levy D. Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Kidney Int. 1999;56:2214–9.CrossRefPubMedGoogle Scholar
  44. 44.
    EVOLVE Trial Investigators, Chertow GM, Block GA, Correa-Rotter R, et al. Effect of cinacalcet on cardiovascular disease in patients undergoing dialysis. N Engl J Med. 2012;367:2482–94.CrossRefGoogle Scholar
  45. 45.
    Besarab A, Bolton WK, Browne JK, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med. 1998;339:584–90.CrossRefPubMedGoogle Scholar
  46. 46.
    Eknoyan G, Beck GJ, Cheung AK, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med. 2002;347:2010–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Paniagua R, Amato D, Vonesh E, et al. Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: Ademex, a prospective, randomized, controlled trial. J Am Soc Nephrol. 2002;13:1307–20.PubMedGoogle Scholar
  48. 48.
    Thadhani R, Appelbaum E, Pritchett Y, et al. Vitamin D therapy and cardiac structure and function in patients with chronic kidney disease: the PRIMO randomized controlled trial. JAMA. 2012;307:674–84.CrossRefPubMedGoogle Scholar
  49. 49.
    Fellstrom BC, Jardine AG, Schmieder RE, et al. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. N Engl J Med. 2009;360:1395–407.CrossRefPubMedGoogle Scholar
  50. 50.
    Johansen KL, et al. Association of body size with outcomes among patients beginning dialysis. Am J Clin Nutr. 2004;80(2):324–32.CrossRefPubMedGoogle Scholar
  51. 51.
    Noori N, Kovesdy CP, Dukkipati R, et al. Survival predictability of lean and fat mass in men and women undergoing maintenance hemodialysis. Am J Clin Nutr. 2010;92:1060–70.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Postorino M, Marino C, Tripepi G, Zoccali C. Abdominal obesity and all-cause and cardiovascular mortality in end stage renal disease. J Am Coll Cardiol. 2009;53:1265–72.CrossRefPubMedGoogle Scholar
  53. 53.
    •• Marcelli D, Usvyst LA, Kotanko P, Bayh I, Canaud B, Etter M, et al. Body composition and survival in dialysis patients: results from an international cohort study. Clin J Am Soc Nephrol. 2015;10:1192–200. Original Article: BMI could be misleading. LBM and FM could offer better prognosis in obesity paradox in ESRD. CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    • Kalantar-Zadeh K, Streja E, Kovesdy C, Oreopoulos A, Noori N, Jing J, et al. The obesity paradox and mortality associated with surrogates of body size and muscle mass in patients receiving hemodialysis. Mayo Clin Proc. 2010;85:991–1001. Original Article: improved survival in MHD when gained muscle mass. CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Kalantar-Zadeh K, Streja E, Molnar MZ, Lukowsky LR, Krishnan M, Kovesdy CP, et al. Mortality prediction by surrogates of body composition: an examination of the obesity paradox in hemodialysis patients using composite ranking score analysis. Am J Epidemoil. 2012;175:793–803.CrossRefGoogle Scholar
  56. 56.
    Sakao Y, Ojima T, Yasuda H, Hashimoto S, Haseqawa T, Iseki K, et al. Serum creatinine modifies associations between body mass index and mortality and morbidity in prevalent hemodialysis patients. PLoS One. 2016;11:e0150003.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Hoogeveen EK, Halbesma N, Rothman KJ, Stijnen T, Dijk SV, Dekker FW, et al. The Netherlands Cooperative Study on the Adequacy of Dialysis-2 (NECOSAD) study group. Clin J Am Soc Nephrol. 2012;7:280–8.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Vashistha T, Mehrotra R, Park J, Streja E, Dukkipati R, Nissenson AR, et al. Effect of age and dialysis vintage on obesity paradox in long-term hemodialysis patients. Am J Kidney Dis. 2014;63:612–22.CrossRefPubMedGoogle Scholar
  59. 59.
    Lee MB, Bargman JM. Myths in peritoneal dialysis. Curr Opin Nephrol Hypertens. 2016;25(6):602–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Nolph KD, Jensen RA, Khanna R, Twardowski ZJ. Weight limitations for weekly urea clearances using various exchange volumes in continuous ambulatory peritoneal dialysis. Perit Dial Int. 1994;14(3):261–4.PubMedGoogle Scholar
  61. 61.
    Ananthakrishnan S, Sekercioglu N, Elias RM, et al. Peritoneal dialysis outcomes in a modern cohort of overweight patients. Int Urol Nephrol. 2014;46(1):183–9.CrossRefPubMedGoogle Scholar
  62. 62.
    Obi Y, Streja E, Mehrotra R, et al. Impact of obesity on modality longevity, residual kidney function, peritonitis, and survival among incident peritoneal dialysis patients. Am J Kidney Dis. 2017.Google Scholar
  63. 63.
    • Snyder JJ, Foley RN, Gilbertson DT, Vonesh EF, Collins AJ. Body size and outcomes on peritoneal dialysis in the United States. Kidney Int. 2003;64(5):1838–44. Original Article: obese dialysis initiated on PD had lower mortality rate compared to HD. CrossRefPubMedGoogle Scholar
  64. 64.
    Prasad N, Sinha A, Gupta A, et al. Effect of body mass index on outcomes of peritoneal dialysis patients in India. Perit Dial Int. 2014;34(4):399–408.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    • Jin H, Shin JY, Lee SH, Song JH, Kim MJ, Lee SW. Abdominal obesity and mortality in continuous ambulatory peritoneal dialysis patients. Electrolyte Blood Press. 2015;13(1):22–9. Original Article: Abdominal circumference in PD patients have similar outcomes as those smaller abdomens.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Castro ACM, Bazanelli AP, Nerbass FB, Cuppari L, Kamimura MA. Waist circumference as a predictor of mortality in peritoneal dialysis patients: a follow-up study of 48 months. Br J Nutr. 2017;117(9):1299–303.CrossRefPubMedGoogle Scholar
  67. 67.
    Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LYC, et al. Comparison of mortality in all patients on dialysis awaiting transplantation, and recipients of a first cadaeric transplant. N Engl J Med. 1999;341:1725–30.CrossRefPubMedGoogle Scholar
  68. 68.
    Holley JL, Shapiro R, Lopatin WB, Txakis AG, Hakala TR, Starzl TE. Obesity as a risk factor following cadaveric renal transplantation. Transplantation. 1990;49:387–9.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Bardonnaud N, Pillot P, Lillaz J, Delorme G, Chabannes E, Bernardini S, et al. Outcomes of renal transplantation in obese recipients. Transplant Proc. 2012;44:2787–91.CrossRefPubMedGoogle Scholar
  70. 70.
    Behzadi AH, Kamali K, Zargar M, Abbasi MA, Piran P, Bastani B. Obesity and urologic complications after renal transplantation. Saudi J Kidney Dis Transpl. 2014;25:303–8.CrossRefPubMedGoogle Scholar
  71. 71.
    •• Scandling JD, et al. Kidney transplant candidate evaluation. Semin Dial. 2005;18:487–94. Review Article: majority of obese patient with BMI > 35 kg/m2 get excluded from pre-transplant waiting list. CrossRefPubMedGoogle Scholar
  72. 72.
    Lentine KL, Delos Santos R, Axelrod D, Schnitzler MA, Brennan DC, Tuttle-Newhall JE. Obesity and kidney transplant candidates: how big is too big for transplantation? Am J Nephrol. 2012;36:575–86.CrossRefPubMedGoogle Scholar
  73. 73.
    Ho B, Skaro AI, Abecassis MM. Should both UNOS and CMS provide regulatory oversight in kidney transplantation ? Curr Transpl Rep. 2015;2:127–34.CrossRefGoogle Scholar
  74. 74.
    • Glanton CW, Kao TC, Cruess D, et al. Impact of renal transplantation on survival in end-stage renal disease patients with elevated body mass index. Kidney Int. 2003;63:647–53. Original Article: impact of renal transplantation on obese dialysis patient surivival. CrossRefPubMedGoogle Scholar
  75. 75.
    Streja E, Molnar M, Kovesdy CP, Bunnapradist S, Jing J, Nissenson AR, et al. Associations of pre-transplant weight and muscle mass with mortality in renal transplant recipients. Clin J Am Soc Nephrol. 2011;6:1463–73.CrossRefPubMedPubMedCentralGoogle Scholar
  76. 76.
    Gill JS, Lan J, Dong J, Rose C, Hendren E, Johnston O. The survival benefit of kidney transplantation in obese patients. Am J Transplant. 2013;13:2083–90.CrossRefPubMedGoogle Scholar
  77. 77.
    Giulianotti P, Gorodner V, Sbrana F, Tzvetanov I, Jeon H, Bianco F, et al. Robotic transabdominal kidney transplantation in a morbidly obese patients. Am J Transplant. 2010;10:1478–82.CrossRefPubMedGoogle Scholar
  78. 78.
    • Oberholzer J, Giulianotti P, Danielson KK, Spaggiari M, Bejarano PL, Bianco F, et al. Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation. Am J Transplant. 2013;13:721–8. Original Article: RAKT in morbid obese dialysis patient showing impressive and promising results. CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    •• Garcia-Roca R, Garcia-Aroz S, Tzvetanov I, Jeon H, Oberholzer J, Benedetti E. Single center experience with robotic kidney transplantation for recipients with BMI of 40 kg/m2 or greater: a comparison with the UNOS Registry. Transplantation. 2017;101:191–6. Review article: comparing RAKT vs open kidney transplant at 3 years. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Medicine, Department of Medicine, Section of Nephrology and HypertensionLouisiana State University Health Sciences Center-New OrleansNew OrleansUSA

Personalised recommendations