Skip to main content

Main menu

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • JASN Podcasts
    • Article Collections
    • Archives
    • Kidney Week Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • Editorial Fellowship
    • Editorial Fellowship Team
    • Editorial Fellowship Application Process
  • More
    • About JASN
    • Advertising
    • Alerts
    • Feedback
    • Impact Factor
    • Reprints
    • Subscriptions
  • ASN Kidney News
  • Other
    • ASN Publications
    • CJASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology

User menu

  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
American Society of Nephrology
  • Other
    • ASN Publications
    • CJASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology
  • Subscribe
  • My alerts
  • Log in
  • My Cart
Advertisement
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • JASN Podcasts
    • Article Collections
    • Archives
    • Kidney Week Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • Editorial Fellowship
    • Editorial Fellowship Team
    • Editorial Fellowship Application Process
  • More
    • About JASN
    • Advertising
    • Alerts
    • Feedback
    • Impact Factor
    • Reprints
    • Subscriptions
  • ASN Kidney News
  • Follow JASN on Twitter
  • Visit ASN on Facebook
  • Follow JASN on RSS
  • Community Forum
Nephrology beyond JASN
You have accessRestricted Access

Radiocontrast-Induced Acute Renal Failure—Impact beyond the Acute Phase

Contrast-Induced Nephropathy after Percutaneous Coronary Interventions in Relation to Chronic Kidney Disease and Hemodynamic Variables. Am J Cardiol 95: 13–19, 2005

Dangas G., Iakovou I., Nikolsky E., Aymong E.D., Mintz G.S., Kipshidze N.N., Lansky A.J., Moussa I., Stone G.W., Moses J.W., Leon M.B. and Mehran R.
JASN March 2006, 17 (3) 595-599; DOI: https://doi.org/10.1681/ASN.2006010061
Dangas G.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Iakovou I.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nikolsky E.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Aymong E.D.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mintz G.S.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kipshidze N.N.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Lansky A.J.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Moussa I.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Stone G.W.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Moses J.W.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Leon M.B.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mehran R.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • View PDF
Loading

Radiocontrast-induced nephropathy is a well known consequence of cardiologic interventions. Acute radiocontrast nephropathy is the third most common cause of acute renal failure in patients admitted to a hospital (1). Up to 7% of patients with this condition need temporary dialysis or progress to end-stage renal disease (2). Radiocontrast nephropathy does not only cause extended hospitalization and increased cost (3), but is also associated with an increased risk of death (4). Numerous studies have identified predisposing risk factors such as preexisting chronic kidney disease (CKD), particularly diabetic kidney disease, degree of renal dysfunction, volume depletion, coadministration of nephrotoxic agents, high doses of radiocontrast, particularly ionic and high osmolar, repeated examinations at short intervals, as well as advanced cardiac failure (5,6), perhaps also age, smoking, and hypercholesterolemia (7).

The study of McCullough et al. (3) examined the outcomes of 1826 consecutive patients undergoing coronary intervention to establish predictors of acute renal failure and examined a second set of 1869 patients to validate the criteria established in the first series. In this population the incidence of acute renal failure was 147/1000 patients and the incidence of acute renal failure requiring dialysis 7.7/1000 patients. Dialysis-dependent acute renal failure was not observed in patients who had received <100 ml radiocontrast and those who had a creatinine clearance >47 ml/min. Creatinine clearance, diabetes, and radiocontrast dose were independent predictors. For those patients with acute renal failure requiring dialysis, the in-hospital mortality was 35.7% and 2-yr survival was as low as 18.8%.

In another series of 439 consecutive patients with elevated S-creatinine (>1.8mg/dl) before the percutaneous coronary intervention, it had been well documented that 37% (n = 161) had a rise in serum creatinine of >25% or required dialysis (8); 22.6% of the dialysed patients died in the hospital, underlining the adverse prognosis. Four patients were discharged on chronic dialysis. Renal function was a powerful predictor of cumulative 1-yr mortality: 45.2% in those requiring dialysis, 35.4% in those experiencing an increase in serum creatinine, and only 19.4% in those with no increase in serum creatinine. Poor hemodynamic parameters in the intensive care unit are known to predict in-hospital acute renal failure (9).

While the above studies had established an intuitively plausible finding, i.e., that renal complications are particularly common in patients with impaired renal function at baseline before cardiological intervention, the renal scenario in patients with normal creatinine concentrations at baseline before coronary angioplasty had not been well documented so far. This prompted Dangas et al. to investigate the incidence, the predictors, and the outcome of contrast nephropathy in such patients. The data were collected prospectively by independent monitors and were analyzed retrospectively. The authors assessed 7230 consecutive patients with or without CKD in one institution (10) undergoing first percutaneous coronary intervention (angioplasty, stenting, directional atherectomy, rotablation). The diagnosis of CKD was based on eGFR according to the Levey Modification of Diet in Renal Disease formula (11), with a cut-off value of <60 ml/min per 1.73 m2. Contrast-induced nephropathy was defined as an increase in serum creatinine 48 h after the procedure to values >25% or >0.5 mg/dl above the value of serum creatinine before the procedure. According to this definition, contrast-induced nephropathy was found in 19.2% of the patients with CKD, but also in a surprisingly high percentage (13.1%) of patients without CKD. Not only duration of in-hospital stay and frequency of in-hospital complications, but also 1-yr mortality was significantly higher in patients with contrast nephropathy—and this was seen regardless of the baseline renal function. Not unexpectedly, the 1-yr mortality was predicted by lower eGFR (12) and other known factors such as age, diabetes mellitus, left ventricular dysfunction, and further indices of cardiac malfunction such as periprocedural hypotension or selection of intra-aortic, balloon-assisted, percutaneous coronary intervention. But when analyzed by multivariate analysis the occurrence of contrast nephropathy was one of the most powerful predictors of the 1-yr mortality, irrespective of the presence (odds ratio 2.37; 95% confidence interval 1.63 to 3.44) or absence of CKD at baseline (odds ratio 1.78; 95% confidence interval 1.22 to 2.60). Although the frequency of contrast nephropathy was less in patients without CKD at baseline, contrast nephropathy was predicted by the same risk factors. The increase of mortality in patients with a history of contrast nephropathy was higher with incremental values of creatinine after the procedure and was maximal when in-hospital dialysis was required, in line with previous observations in a different cohort (3). Remarkable is the finding that higher 1-yr mortality was not accounted for by more frequent myocardial infarction or need for revascularization procedures. Other factors must be responsible for the adverse late outcome and the most plausible explanation is a higher hemodynamic and atherosclerotic burden in patients developing contrast nephropathy, which then also predisposes to late mortality. This burden is presumably further aggravated by contrast nephropathy for instance by pathomechanisms such as activation of the renin-angiotensin system, triggering an inflammatory response, and further deterioration of cardiovascular function.

Can contrast nephropathy can be prevented ? Although this was not a prospective, interventional study, some points are of interest in this context. First, the dose of radiocontrast (factored for body surface) was clearly related to the risk of contrast nephropathy. Second, in view of conflicting reports in the past concerning the effect of angiotensin-converting enzyme inhibitors on the risk of contrast nephropathy, which noted either more adverse (13) or less adverse (14) renal outcomes, it is of interest that in the present study treatment with angiotensin-converting enzyme inhibitors tended to reduce the frequency of contrast nephropathy.

The study illustrates that the occurrence of contrast nephropathy confers a high risk even far beyond the hospital stay. A recent observational study is even compatible with the hypothesis that a history of exposure to radiocontrast increases the risk of delayed end-stage renal disease (15).

Figure

Eberhard Ritz Feature Editor

Footnotes

  • Address correspondence to: Prof. Eberhard Ritz, Department Internal Medicine, Division of Nephrology, Bergheimer Strasse 56a, D-69115 Heidelberg, Germany. Phone: 49-0-6221-601705 or 49-0-6221-189976; Fax: 49-0-6221-603302; E-mail: Prof.E.Ritz{at}t-online.de

  • © 2006 American Society of Nephrology

References

  1. ↵
    Nash K, Hafeez A, Hou S: Hospital-acquired renal insufficiency. Am J Kidney Dis 39 : 930 –936, 2002
    OpenUrlCrossRefPubMed
  2. ↵
    Lameire N, Van Biesen W, Vanholder R: Acute renal failure. Lancet 365 : 417 –430, 2005
    OpenUrlCrossRefPubMed
  3. ↵
    McCullough PA, Wolyn R, Rocher LL, Levin RN, O’Neill WW: Acute renal failure after coronary intervention: Incidence, risk factors, and relationship to mortality. Am J Med 103 : 368 –375, 1997
    OpenUrlCrossRefPubMed
  4. ↵
    Levy EM, Viscoli CM, Horwitz RI: The effect of acute renal failure on mortality. A cohort analysis. JAMA 275 : 1489 –1494, 1996
    OpenUrlCrossRefPubMed
  5. ↵
    Chertow GM: Prevention of radiocontrast nephropathy: Back to basics. JAMA 291 : 2376 –2377, 2004
    OpenUrlCrossRefPubMed
  6. ↵
    Weisbord SD, Palevsky PM: Radiocontrast-induced acute renal failure. J Intensive Care Med 20 : 63 –75, 2005
    OpenUrlCrossRefPubMed
  7. ↵
    Lindholt JS: Radiocontrast induced nephropathy. Eur J Vasc Endovasc Surg 25 : 296 –304, 2003
    OpenUrlCrossRefPubMed
  8. ↵
    Gruberg L, Mintz GS, Mehran R, Gangas G, Lansky AJ, Kent KM, Pichard AD, Satler LF, Leon MB: The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 36 : 1542 –1548, 2000
    OpenUrlCrossRefPubMed
  9. ↵
    McCullough PA, Soman SS, Shah SS, Smith ST, Marks KR, Yee J, Borzak S: Risks associated with renal dysfunction in patients in the coronary care unit. J Am Coll Cardiol 36 : 679 –684, 2000
    OpenUrlCrossRefPubMed
  10. ↵
    Dangas G, Iakovou I, Nikolsky E, Aymong ED, Mintz GS, Kipshidze NN, Lansky AJ, Moussa I, Stone GW, Moses JW, Leon MB, Mehran R: Contrast-induced nephropathy after percutaneous coronary interventions in relation to chronic kidney disease and hemodynamic variables. Am J Cardiol 95 : 13 –19, 2005
    OpenUrlCrossRefPubMed
  11. ↵
    Manjunath G, Tighiouart H, Coresh J, Macleod B, Salem DN, Griffith JL, Levey AS, Sarnak MJ: Level of kidney function as a risk factor for cardiovascular outcomes in the elderly. Kidney Int 63 : 1121 –1129, 2003
    OpenUrlCrossRefPubMed
  12. ↵
    Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY: Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 351 : 1296 –1305, 2004
    OpenUrlCrossRefPubMed
  13. ↵
    Kini AS, Mitre CA, Kim M, Kamran M, Reich D, Sharma SK: A protocol for prevention of radiographic contrast nephropathy during percutaneous coronary intervention: Effect of selective dopamine receptor agonist fenoldopam. Catheter Cardiovasc Interv 55 : 169 –173, 2002
    OpenUrlCrossRefPubMed
  14. ↵
    Gupta RK, Kapoor A, Tewari S, Sinha N, Sharma RK: Captopril for prevention of contrast-induced nephropathy in diabetic patients: A randomised study. Indian Heart J 51 : 521 –526, 1999
    OpenUrlPubMed
  15. ↵
    Muntner P, Coresh J, Klag MJ, Whelton PK, Perneger TV: Exposure to radiologic contrast media and an increased risk of treated end-stage renal disease. Am J Med Sci 326 : 353 –359, 2003
    OpenUrlCrossRefPubMed

MHC-Independent Allorecognition of Invertebrates—A Link between Invertebrate Histocompatibility and Vertebrate Adaptive Immunity?

The molecular basis of the adaptive immunity of vertebrates, preserved from sharks to humans, is peptide presentation by the highly polymorphic major histcompatibiliy complex (MHC). Histocompatibility, i.e., the ability to distinguish the organism’s own cells from another organism’s cells, is found throughout the metazoan species. MHC, the key molecules for allorecognition in all vertebrates from sharks to humans, have not been found in the animal kingdom in species other than vertebrates, even when the closest relatives of vertebrates, the jawless fish, were studied (1).

It is against this background that the exciting findings of the Stanford group in the Monterey Marine Station are a genuine breakthrough. They define an ancient form of MHC-independent allorecognition (2). The authors studied a species of chordates, the ascidian Botryllus schlosseri, a small marine organism. The lifecycle of this species includes a free-living sexual stage and a sedentary asexual stage. In the asexual stage colonies of asexually derived, genetically identical individuals, so-called zooids, are embedded in a gelatinous mass, are united by a common vascular network, and grow by budding. When different colonies approach each other, the foremost protruding tissue, so-called ampullae, come into contact. It had been known that such encounters may lead to two opposite outcomes: Either the ampullae fuse and eventually circulating stem cells are exchanged through the interconnecting vascular systems, or a rejection reaction occurs (not unlike the rejection reaction in vertebrates), i.e., the ampullae are destroyed by necrosis, the vascular systems fail to fuse, and there is evidence of local inflammation.

Undoubted analogies exist with the allorecognition in jawed vertebrates where success or failure of grafts is determined by the molecules encoded by the MHC-I and MHC-II genes (3). In the nonvertebrate species B. schlosseri, the novel finding is that here allorecognition is under the control of a gene completely unrelated to MHC. The decision whether fusion or rejection occurs is governed by a single, highly polymorphic locus, the fusion/histocompatibility (FuHC) gene (4): When two colonies share one or both FuHC alleles they will fuse; if they don’t share any common allele, rejection occurs. The analogy to MHC goes even further: FuHC is highly polymorphic. Most populations of B. schlosseri contain tens to hundreds of alleles (4).

The aim of the study by De Tomaso et al. was the molecular characterization of the FuHC genes. To this end the authors bred B. schlosseri in captivity and developed inbred lines homozygous for different FuHC genes. Using such FuHC-defined cultures, the FuHC locus was mapped using techniques such as amplified fragment length polymorphism, bulk segregant analysis, and genomic walking. The FuHC gene was found to code for a transmembrane protein with an extracellular Ig domain. The open reading frame predicted a highly polymorphic protein of 1007 amino acids. Two Ig domains, which differed with respect to their genomic structure, were homologous to Ig superfamily members (IGSF4D) of vertebrate species. The authors also predicted a secreted form arising as a result of alternative splicing and a series of further variants of unknown function.

The functional importance of this highly polymorphic gene was then evaluated by testing its relation to the above described functional histocompatibility reaction as assessed by the fusion/rejection assay. The polymorphisms of the FuHC gene segregated absolutely with this histocompatibility reaction. Fusion was consistently seen in animals that shared an identical allele and, conversely, rejection was never seen when an allele was shared.

What are the implications of the finding of this first metazoan histocompatibility ligand identified outside of the vertebrate lineage? In a seminal paper, Burnet had argued that the ability to discriminate between multiple different ligands is shared by immunity and by histocompatibility (5). Based on this consideration Burnet put forward the hypothesis that the origins of the vertebrate adaptive immune system were rooted in the histocompatibility systems of more primitive metazoic organisms. Is the FuHC molecule the missing link?

Certainly there are structural similarities between the vertebrate MHC molecule and the FuHC type I transmembrane protein, which contains multiple extracellular Ig domains. Nevertheless, it is not a strict homologue. It is known that the adaptive immune system arose in ancestors of the jawed vertebrates approximately 500 million years ago. While homologues of immunoglobulins, T cell receptors, major histocompatibility complexes (MHC), and recombination activating genes (RAG) have been found in all jawed vertebrates, none of these genes or close homologues have been identified in jawless vertebrates or invertebrates (6). It has been postulated, however, that the molecules involved in adaptive immunity go back to “fossil” genes of invertebrates. It has been suspected that primitive species without the machinery for recombination (RAG) contain a “primordial receptor” (6)—is FuHC a candidate?

With respect to how the FuHC molecule works, the authors came up with an interesting suggestion. In B. schlosseri, individuals sharing only a single allele are compatible. One possibility would be that two identical molecules “recognize” each other by homotypic interaction—but an alternative appears more attractive. Apart from recognizing foreign antigens in the context of self MHC, a more primitive complementary defense system has recently been described in vertebrates, i.e., missing-self-recognition (7), which is operative in natural killer cells. When cells don’t express “self” molecules they are attacked and eliminated. This mechanism may be useful to prevent aberrant tumor cells that fail to express MHC products, thus avoiding detection and destruction. De Tomaso et al. speculate that this natural killer cell system in vertebrates, which has a forerunner in invertebrates, e.g., in the ascidian Ciona intestinalis (8), and at least the mode of operation has also been adopted by FuHC.

The most challenging possibility is that FuHC represents an undiscovered Ig-based system of allorecognition that still exists in vertebrates, analogous to the missing self recognition mode in natural killer cells, which interact with ligands other than members of the MHC family (non-MHC ligands) (9).

It is fascinating how much can be learned by going back to the roots and studying primitive model organisms that share key mechanisms with the higher species, beautifully illustrating the “unity of nature” that had been so well anticipated by the poet and philosopher Johann Wolfgang von Goethe (1749–1832).

References

  1. ↵
    Litman GW: Histocompatibility: Colonial match and mismatch. Nature 438 : 437 –439, 2005
    OpenUrlCrossRefPubMed
  2. ↵
    De Tomaso AW, Nyholm SV, Palmeri KJ, Ishizuka KJ, Ludington WB, Mitchel K, Weissman IL: Isolation and characterization of a protochordate histocompatibility locus. Nature 438 : 454 –459, 2005
    OpenUrlCrossRefPubMed
  3. ↵
    Charron D: Immunogenetics today: HLA, MHC and much more. Curr Opin Immunol 17 : 493 –497, 2005
    OpenUrlCrossRefPubMed
  4. ↵
    De Tomaso AW, Weissman IL: Initial characterization of a protochordate histocompatibility locus. Immunogenetics 55 : 480 –490, 2003
    OpenUrlCrossRefPubMed
  5. ↵
    Burnet FM: “Self-recognition” in colonial marine forms and flowering plants in relation to the evolution of immunity. Nature 232 : 230 –235, 1971
    OpenUrlCrossRefPubMed
  6. ↵
    Cannon JP, Haire RN, Rast JP, Litman GW: The phylogenetic origins of the antigen-binding receptors and somatic diversification mechanisms. Immunol Rev 200 : 12 –22, 2004
    OpenUrlCrossRefPubMed
  7. ↵
    Karre K, Ljunggren HG, Piontek G, Kiessling R: Selective rejection of H-2-deficient lymphoma variants suggests alternative immune defence strategy. Nature 319 : 675 –678, 1986
    OpenUrlCrossRefPubMed
  8. ↵
    Azumi K, De Santis R, De Tomaso A, Rigoutsos I, Yoshizaki F, Pinto MR, Marino R, Shida K, Ikeda M, Arai M, Inoue Y, Shimizu T, Satoh N, Rokhsar DS, Du Pasquier L, Kasahara M, Satake M, Nonaka M: Genomic analysis of immunity in a Urochordate and the emergence of the vertebrate immune system: “Waiting for Godot”. Immunogenetics 55 : 570 –581, 2003
    OpenUrlCrossRefPubMed
  9. ↵
    Carlyle JR, Jamieson AM, Gasser S, Clingan CS, Arase H, Raulet DH: Missing self-recognition of Ocil/Clr-b by inhibitory NKR-P1 natural killer cell receptors. Proc Natl Acad Sci U S A 101 : 3527 –3532, 2004
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top

In this issue

Journal of the American Society of Nephrology: 17 (3)
Journal of the American Society of Nephrology
Vol. 17, Issue 3
March 2006
  • Table of Contents
  • Index by author
View Selected Citations (0)
Print
Download PDF
Sign up for Alerts
Email Article
Thank you for your help in sharing the high-quality science in JASN.
Enter multiple addresses on separate lines or separate them with commas.
Radiocontrast-Induced Acute Renal Failure—Impact beyond the Acute Phase
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Radiocontrast-Induced Acute Renal Failure—Impact beyond the Acute Phase
Dangas G., Iakovou I., Nikolsky E., Aymong E.D., Mintz G.S., Kipshidze N.N., Lansky A.J., Moussa I., Stone G.W., Moses J.W., Leon M.B., Mehran R.
JASN Mar 2006, 17 (3) 595-599; DOI: 10.1681/ASN.2006010061

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
Radiocontrast-Induced Acute Renal Failure—Impact beyond the Acute Phase
Dangas G., Iakovou I., Nikolsky E., Aymong E.D., Mintz G.S., Kipshidze N.N., Lansky A.J., Moussa I., Stone G.W., Moses J.W., Leon M.B., Mehran R.
JASN Mar 2006, 17 (3) 595-599; DOI: 10.1681/ASN.2006010061
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Footnotes
    • References
    • References
  • Info & Metrics
  • View PDF

More in this TOC Section

  • Metabolic Syndrome—What We Know and What We Don't Know
  • Cardiovascular Events and Parathyroid Hormone—Suggestion of a Further Link
  • Endothelial Cell Dysfunction—Can One Outsmart Oxidative Stress by Direct Interaction with the Pathological Oxidized or Heme-Free Soluble Guanyl-Cyclase?
Show more Nephrology beyond JASN

Cited By...

  • No citing articles found.
  • Google Scholar

Similar Articles

Related Articles

  • No related articles found.
  • Google Scholar

Articles

  • Current Issue
  • Early Access
  • Subject Collections
  • Article Archive
  • ASN Annual Meeting Abstracts

Information for Authors

  • Submit a Manuscript
  • Author Resources
  • Editorial Fellowship Program
  • ASN Journal Policies
  • Reuse/Reprint Policy

About

  • JASN
  • ASN
  • ASN Journals
  • ASN Kidney News

Journal Information

  • About JASN
  • JASN Email Alerts
  • JASN Key Impact Information
  • JASN Podcasts
  • JASN RSS Feeds
  • Editorial Board

More Information

  • Advertise
  • ASN Podcasts
  • ASN Publications
  • Become an ASN Member
  • Feedback
  • Follow on Twitter
  • Password/Email Address Changes
  • Subscribe to ASN Journals
  • Wolters Kluwer Partnership

© 2022 American Society of Nephrology

Print ISSN - 1046-6673 Online ISSN - 1533-3450

Powered by HighWire