This document discusses vaccination in patients with chronic kidney disease (CKD). It outlines how CKD affects both the innate and adaptive immune systems, leading to impaired immunity. It describes alterations in end-stage renal disease that impair response to vaccines. Guidelines recommend vaccines for hepatitis B, pneumococcus, and influenza for CKD patients, with some vaccines requiring higher doses or more doses. Methods to potentially improve vaccine efficacy include use of immunomodulators like interleukin-2 administered with vaccines.
The document discusses vaccination in patients with chronic kidney disease (CKD). It outlines the rationale and recommendations for vaccination in CKD patients, including those undergoing dialysis or renal transplantation. Specific recommendations are provided for pneumococcal vaccination in CKD patients based on guidelines. The summary discusses how CKD and end-stage renal disease can impair immune function, making vaccinations less effective, and the importance of vaccinating CKD patients to prevent infectious diseases.
1. Patients with chronic kidney disease (CKD) have impaired immune responses that increase their risk of infections. Vaccinations are an important prevention strategy, though CKD patients typically have lower vaccine effectiveness compared to those with healthy kidneys.
2. Key recommended vaccinations for CKD patients include: hepatitis B vaccine (4 doses of 40 μg), influenza vaccine (annual 15 μg doses), and pneumococcal vaccine (single 0.5 mL dose). These vaccines have shown protective benefits, though antibody responses tend to be lower in CKD patients.
3. Additional strategies to improve vaccine responses include earlier vaccination as kidney function declines, intradermal administration, and booster doses for hepatitis B when antibody levels decline below
1. Dialysis adequacy refers to removing sufficient toxins and waste from the blood to prevent adverse health outcomes and is measured by urea clearance and nutritional intake.
2. Urea clearance is the standard measure and is expressed as Kt/V, with a target single pool Kt/V of at least 1.2 per session for patients receiving hemodialysis 3 times a week.
3. Other factors that determine adequacy include residual kidney function, nutrition as measured by normalized protein catabolic rate, and controlling symptoms like anemia, acidosis, and blood pressure.
This document provides an overview of anticoagulation options for hemodialysis. It discusses conventional anticoagulants like unfractionated heparin and low molecular weight heparins. It also covers newer direct thrombin inhibitors and regional anticoagulation methods using citrate or prostacyclin. The risks and benefits of each option are evaluated based on bleeding risks, reversibility, cost, and ability to prevent clotting during hemodialysis procedures. Monitoring requirements and dosing protocols are also reviewed for different anticoagulant regimens.
This document discusses the management of pregnant women on hemodialysis. It notes that physiological changes during pregnancy can impact kidney function, but intensive hemodialysis of more than 20 hours per week is recommended to reduce risks. Close monitoring of blood pressure, nutrition, mineral levels, anemia and fetal growth is important. Hemodialysis prescription should be tailored to each patient's needs, with adjustments to dialysate composition and blood flow. Vaginal delivery at 38 weeks is typically recommended unless complications arise. A multidisciplinary team of nephrologists, obstetricians and dietitians helps optimize outcomes for these high-risk pregnancies.
1. Lithium is used to treat and prevent mania and bipolar disorder. It works by inhibiting neurotransmitter release in the brain.
2. It is excreted unchanged in the urine, so renal impairment increases the risk of toxicity. The dose must be carefully monitored and reduced in renal impairment.
3. Toxicity can occur even at therapeutic levels and includes tremors, ataxia, confusion, seizures, and cardiac issues. Hemodialysis is required to treat severe toxicity.
Intra dialytic hypotension ,,, prof Alaa SabryFarragBahbah
This document describes a case of intradialytic hypotension in a 65-year-old man on hemodialysis. During one of his dialysis treatments, he developed hypotension with symptoms of feeling poorly and diaphoresis. His dry weight was increased in response, but he experienced another episode of hypotension several days later. The document then discusses intradialytic hypotension in general, including definitions, mechanisms, complications, and approaches to assessing volume status in hemodialysis patients.
kidney disease in HIV-positive patients, Moh'd sharshirMoh'd sharshir
Patients with HIV are at risk for both acute kidney injury and chronic kidney disease due to various factors like medication toxicity, HIV-associated nephropathy, and immune complex kidney diseases. The risk factors for acute kidney injury in HIV patients are similar to the general population but also include factors specific to HIV like low CD4 count and co-infection with hepatitis C virus. Timely screening for chronic kidney disease is important in HIV patients to monitor for decline in kidney function and proteinuria, in order to guide management and reduce risk of end-stage renal disease.
The document discusses vaccination in patients with chronic kidney disease (CKD). It outlines the rationale and recommendations for vaccination in CKD patients, including those undergoing dialysis or renal transplantation. Specific recommendations are provided for pneumococcal vaccination in CKD patients based on guidelines. The summary discusses how CKD and end-stage renal disease can impair immune function, making vaccinations less effective, and the importance of vaccinating CKD patients to prevent infectious diseases.
1. Patients with chronic kidney disease (CKD) have impaired immune responses that increase their risk of infections. Vaccinations are an important prevention strategy, though CKD patients typically have lower vaccine effectiveness compared to those with healthy kidneys.
2. Key recommended vaccinations for CKD patients include: hepatitis B vaccine (4 doses of 40 μg), influenza vaccine (annual 15 μg doses), and pneumococcal vaccine (single 0.5 mL dose). These vaccines have shown protective benefits, though antibody responses tend to be lower in CKD patients.
3. Additional strategies to improve vaccine responses include earlier vaccination as kidney function declines, intradermal administration, and booster doses for hepatitis B when antibody levels decline below
1. Dialysis adequacy refers to removing sufficient toxins and waste from the blood to prevent adverse health outcomes and is measured by urea clearance and nutritional intake.
2. Urea clearance is the standard measure and is expressed as Kt/V, with a target single pool Kt/V of at least 1.2 per session for patients receiving hemodialysis 3 times a week.
3. Other factors that determine adequacy include residual kidney function, nutrition as measured by normalized protein catabolic rate, and controlling symptoms like anemia, acidosis, and blood pressure.
This document provides an overview of anticoagulation options for hemodialysis. It discusses conventional anticoagulants like unfractionated heparin and low molecular weight heparins. It also covers newer direct thrombin inhibitors and regional anticoagulation methods using citrate or prostacyclin. The risks and benefits of each option are evaluated based on bleeding risks, reversibility, cost, and ability to prevent clotting during hemodialysis procedures. Monitoring requirements and dosing protocols are also reviewed for different anticoagulant regimens.
This document discusses the management of pregnant women on hemodialysis. It notes that physiological changes during pregnancy can impact kidney function, but intensive hemodialysis of more than 20 hours per week is recommended to reduce risks. Close monitoring of blood pressure, nutrition, mineral levels, anemia and fetal growth is important. Hemodialysis prescription should be tailored to each patient's needs, with adjustments to dialysate composition and blood flow. Vaginal delivery at 38 weeks is typically recommended unless complications arise. A multidisciplinary team of nephrologists, obstetricians and dietitians helps optimize outcomes for these high-risk pregnancies.
1. Lithium is used to treat and prevent mania and bipolar disorder. It works by inhibiting neurotransmitter release in the brain.
2. It is excreted unchanged in the urine, so renal impairment increases the risk of toxicity. The dose must be carefully monitored and reduced in renal impairment.
3. Toxicity can occur even at therapeutic levels and includes tremors, ataxia, confusion, seizures, and cardiac issues. Hemodialysis is required to treat severe toxicity.
Intra dialytic hypotension ,,, prof Alaa SabryFarragBahbah
This document describes a case of intradialytic hypotension in a 65-year-old man on hemodialysis. During one of his dialysis treatments, he developed hypotension with symptoms of feeling poorly and diaphoresis. His dry weight was increased in response, but he experienced another episode of hypotension several days later. The document then discusses intradialytic hypotension in general, including definitions, mechanisms, complications, and approaches to assessing volume status in hemodialysis patients.
kidney disease in HIV-positive patients, Moh'd sharshirMoh'd sharshir
Patients with HIV are at risk for both acute kidney injury and chronic kidney disease due to various factors like medication toxicity, HIV-associated nephropathy, and immune complex kidney diseases. The risk factors for acute kidney injury in HIV patients are similar to the general population but also include factors specific to HIV like low CD4 count and co-infection with hepatitis C virus. Timely screening for chronic kidney disease is important in HIV patients to monitor for decline in kidney function and proteinuria, in order to guide management and reduce risk of end-stage renal disease.
This document discusses chronic kidney disease (CKD), anemia in CKD, and treatments for anemia in CKD. It defines CKD and its stages based on glomerular filtration rate and kidney damage. Anemia in CKD is defined based on hemoglobin levels. Causes of anemia in CKD include relative erythropoietin deficiency, iron deficiency, blood loss, shortened red blood cell lifespan, and the "uremic milieu." Iron therapy and erythropoiesis-stimulating agents (ESAs) are discussed as treatments for anemia in CKD, including criteria for starting therapy, drug options, dosing, monitoring, and dose adjustment.
The document discusses common complications of hemodialysis including hypotension, muscle cramps, nausea and vomiting, and headache. It notes the percentages of patients experiencing each complication and describes causes such as rapid ultrafiltration, cardiovascular issues, and dialysis disequilibrium syndrome. Prevention strategies are outlined including accurate setting of dry weight and dialysate modifications. Treatment of muscle cramps is also addressed.
This document discusses guidelines for prescribing hemodialysis for acute kidney injury patients. It covers key elements of the prescription including session length and blood flow rate, dialyzer selection, dialysate composition, and ultrafiltration orders. The presentation emphasizes starting more frequent but shorter sessions at lower intensity initially and gradually increasing session length and clearance as the patient stabilizes to prevent dialysis disequilibrium syndrome.
The document discusses the treatment of heart failure in patients with chronic kidney disease. It notes that CKD is a common comorbidity in heart failure patients and that the coexistence of the two conditions increases health risks. The main treatments discussed are:
1. ACE inhibitors and ARBs to improve ventricular function, though they can worsen kidney function. Close monitoring of kidney function and electrolytes is needed.
2. Beta blockers like bisoprolol and carvedilol to improve ventricular function, though they can cause hypotension and kidney dysfunction.
3. Aldosterone antagonists to reduce heart failure worsening and increase survival, though they can cause hyperkalemia and worsen kidney function.
Anemia of renal disease is common and is associated with significant morbidity and death. It is mainly caused by a decrease in erythropoietin production in the kidneys and can be partially corrected with erythropoiesis-stimulating agents (ESAs). However, randomized controlled trials have shown that using ESAs to target normal hemoglobin levels can be harmful, and have called into question any benefits of ESA treatment other than avoidance of transfusions.
This document discusses sustained low-efficiency daily dialysis (SLEDD) for treating acute kidney injury (AKI) in critically ill patients. SLEDD is a hybrid therapy that combines aspects of continuous renal replacement therapy and intermittent hemodialysis. It allows for a reduced ultrafiltration rate and prolonged treatment duration to maximize dialysis dose while maintaining hemodynamic stability. The document outlines the indications for SLEDD, including patients at risk of disequilibrium or with borderline cardiovascular stability. Preliminary studies suggest SLEDD is a safe and effective option for AKI patients otherwise unsuitable for standard therapies.
Dialysis disequilibrium syndrome (DDS) is characterized by neurological symptoms that occur during or after dialysis as a result of a rapid shift in osmoles like urea. It is caused by a transient osmotic gradient between plasma and brain cells as urea is swiftly removed by dialysis, causing water to shift into neurons and produce cerebral edema. Risk factors include the first dialysis treatment or high pre-dialysis BUN. Symptoms range from mild like headache to severe like seizures. Prevention focuses on limiting urea removal during initial sessions by using lower blood and dialysate flows with sodium modeling. Treatment is usually supportive and symptoms resolve within 24 hours.
The patient is a 49-year-old woman with end-stage renal disease and diabetes who presented with altered mental status. She receives hemodialysis three times per week for a few years. Recently, she has been increasingly tired, weak, and unable to perform daily activities with poor appetite and nausea. On examination, she was pale and swollen with low hemoglobin. Tests found elevated creatinine, BUN, and electrolyte abnormalities. The most probable diagnosis is inadequate hemodialysis, as her symptoms and labs are consistent with worsening uremia due to insufficient solute clearance from her dialysis sessions. Kt/V is a measure of dialysis adequacy that accounts for urea clearance and patient
The document discusses various complications that can occur during hemodialysis treatment including intradialytic hypotension, dialyzer reactions, disequilibrium syndrome, cramping, air embolism, hemolysis, cardiac arrhythmias, hemorrhage, pruritus, febrile reactions, hypokalemia, hyperkalemia, and dialysis pericarditis. It describes the etiology, diagnosis, and treatment approaches for each complication.
This document discusses hepatitis B virus (HBV) infection in patients undergoing dialysis or kidney transplantation. Some key points:
1) HBV infection is a concern for dialysis and transplant patients due to their immunosuppressed state, which increases susceptibility to infection and can cause HBV to take a more severe clinical course.
2) While HBV infection may seem relatively mild in dialysis patients, it poses significant risks if they undergo kidney transplantation, as HBV can reactivate or cause life-threatening complications after transplant.
3) Preventing HBV transmission in dialysis units is important through measures like vaccination, protective equipment, and regular screening. Prophylactic treatment is recommended for infected patients considering transplant
Role of erythropoitin in chronic kidney diseaseAftab Siddiqui
1) Erythropoietin (EPO) and novel EPO stimulating proteins (NESPs) play an important role in managing anemia in chronic kidney disease (CKD). EPO therapy aims to increase hemoglobin levels by 1-2 g/dl per month and reduce need for blood transfusions.
2) Intravenous or subcutaneous iron supplementation is also important to manage iron deficiency and allow effective response to EPO. The target is to achieve transferrin saturation between 20-50% and serum ferritin above 100 ng/ml.
3) Causes of resistance to EPO action include iron, folate or carnitine deficiencies, chronic infections, inflammation, and secondary hyperpar
Anemia is a common complication of chronic kidney disease that can cause fatigue. While the kidneys normally produce erythropoietin to stimulate red blood cell production, CKD patients have relative erythropoietin deficiency. This leads to anemia which, if left untreated, can negatively impact quality of life and cardiovascular health. Erythropoiesis-stimulating agents and iron supplementation are used to treat anemia in CKD, though the appropriate hemoglobin target level remains an area of ongoing research and debate given risks identified with higher targets in some studies.
The document discusses acute kidney injury (AKI), defining it, outlining causes and types including prerenal, intrinsic renal and postrenal, describing evaluation through investigations and clinical assessment, prevention and management recommendations including dialysis interventions, and complications of AKI.
This document discusses the management of anemia in chronic kidney disease (CKD). It begins by defining anemia and its causes in CKD, which include reduced erythropoietin production and decreased red blood cell survival due to kidney failure. Left untreated, anemia in CKD can lead to deterioration in cardiac function, impaired cognition, and increased fatigue and mortality risk. The main therapeutic options for treating anemia in CKD are red blood cell transfusions, androgens, and erythropoiesis-stimulating agents (ESAs). ESAs such as epoetin alfa and darbepoetin alfa are now the standard treatment as they reduce transfusion needs and risks while helping to mobilize
This document discusses exit site infections in peritoneal dialysis patients. It defines acute and chronic exit site infections and notes that approximately one fifth of peritonitis episodes are associated with exit or tunnel infections. Exit site infections are commonly caused by Staphylococcus aureus or Gram-negative bacteria like Pseudomonas. Treatment depends on the severity and causative organism but may include antibiotics, changing the exit site dressing, or catheter removal in severe cases. Preventing exit site infections through good catheter care and possibly antibiotic prophylaxis can help reduce risks of peritonitis and catheter loss.
This document discusses hyperphosphatemia, which occurs when phosphate levels in the blood are abnormally high. It provides information on the causes of hyperphosphatemia, which include kidney disease, and discusses guideline target levels and treatment options. Treatment involves phosphate restriction, phosphate binders such as aluminum hydroxide, calcium salts, and newer non-calcium binders. Novel therapies being researched include nicotinamide and iron-based compounds. The goal is to manage phosphate levels through diet, medication and dialysis to prevent complications in patients with chronic kidney disease.
The document summarizes potential complications of peritoneal dialysis catheters including malfunctioning catheters, early and late non-functioning, and causes such as constipation, intra-abdominal adhesions from previous surgery or peritonitis, catheter migration, blood or fibrin blocking the catheter, and hernias. It describes methods for investigating malfunctioning catheters including abdominal x-rays, x-rays with contrast dye, and CT scans. It provides guidance on managing different causes through measures like laxatives, re-siting the catheter, adding heparin to dialysate, or removing the catheter.
Catheter related infections atmeda final (1)FarragBahbah
This document discusses catheter-related infections in hemodialysis patients. It covers definitions of different types of infections, pathogenesis, epidemiology, diagnosis, treatment, and prevention strategies. The most common causative pathogens are coagulase-negative staphylococci, S. aureus, enterococci, and Candida species. Antibiotic lock solutions can be used to reduce infections and allow catheter salvage in some cases. Strict adherence to infection control practices and prioritizing arteriovenous fistulas can help reduce catheter-related infections.
The document discusses complications of peritoneal dialysis, specifically peritonitis. It describes the typical presentation of peritonitis as abdominal pain and cloudy dialysate fluid. Causes include breaks in sterile technique or recent infections. Diagnosis requires abdominal pain and cloudy fluid with leukocytosis. Treatment involves empiric antibiotics targeting gram positive and negative organisms. Outcomes depend on causative organisms and whether the peritoneal catheter is infected.
IMMUNODEFICIENCY DISORDERS GROUP 6A.pptxYvonneMwita
This document discusses immunodeficiency diseases. It defines immunodeficiency as a state where the immune system's ability to fight infections is compromised or absent. There are two types: primary immunodeficiency which is inherited and diagnosed in childhood, and secondary immunodeficiency which is acquired from diseases or environmental factors like HIV. Primary immunodeficiencies are classified into humoral deficiencies, cellular deficiencies, combined deficiencies, complement disorders, and phagocytosis disorders. Examples like X-linked agammaglobulinemia and common variable immunodeficiency are described. Nursing management focuses on infection assessment, patient teaching, and supportive care.
This document discusses various biologic therapies used to treat kidney diseases. It defines biologics as substances derived from biological sources using biotechnology. Biologics are classified into categories including hormones, growth factors, cytokines, vaccines, enzymes and antibodies. Specific biologics discussed that target the immune system include monoclonal antibodies against TNFα, IL-2, IL-6, CD20, C5, VEGF, and TWEAK. Conditions where biologics may be used include glomerular diseases, transplantation, lupus nephritis, ANCA-associated vasculitis, and hepatitis C infection. Potential benefits and risks of different biologics are presented.
This document discusses chronic kidney disease (CKD), anemia in CKD, and treatments for anemia in CKD. It defines CKD and its stages based on glomerular filtration rate and kidney damage. Anemia in CKD is defined based on hemoglobin levels. Causes of anemia in CKD include relative erythropoietin deficiency, iron deficiency, blood loss, shortened red blood cell lifespan, and the "uremic milieu." Iron therapy and erythropoiesis-stimulating agents (ESAs) are discussed as treatments for anemia in CKD, including criteria for starting therapy, drug options, dosing, monitoring, and dose adjustment.
The document discusses common complications of hemodialysis including hypotension, muscle cramps, nausea and vomiting, and headache. It notes the percentages of patients experiencing each complication and describes causes such as rapid ultrafiltration, cardiovascular issues, and dialysis disequilibrium syndrome. Prevention strategies are outlined including accurate setting of dry weight and dialysate modifications. Treatment of muscle cramps is also addressed.
This document discusses guidelines for prescribing hemodialysis for acute kidney injury patients. It covers key elements of the prescription including session length and blood flow rate, dialyzer selection, dialysate composition, and ultrafiltration orders. The presentation emphasizes starting more frequent but shorter sessions at lower intensity initially and gradually increasing session length and clearance as the patient stabilizes to prevent dialysis disequilibrium syndrome.
The document discusses the treatment of heart failure in patients with chronic kidney disease. It notes that CKD is a common comorbidity in heart failure patients and that the coexistence of the two conditions increases health risks. The main treatments discussed are:
1. ACE inhibitors and ARBs to improve ventricular function, though they can worsen kidney function. Close monitoring of kidney function and electrolytes is needed.
2. Beta blockers like bisoprolol and carvedilol to improve ventricular function, though they can cause hypotension and kidney dysfunction.
3. Aldosterone antagonists to reduce heart failure worsening and increase survival, though they can cause hyperkalemia and worsen kidney function.
Anemia of renal disease is common and is associated with significant morbidity and death. It is mainly caused by a decrease in erythropoietin production in the kidneys and can be partially corrected with erythropoiesis-stimulating agents (ESAs). However, randomized controlled trials have shown that using ESAs to target normal hemoglobin levels can be harmful, and have called into question any benefits of ESA treatment other than avoidance of transfusions.
This document discusses sustained low-efficiency daily dialysis (SLEDD) for treating acute kidney injury (AKI) in critically ill patients. SLEDD is a hybrid therapy that combines aspects of continuous renal replacement therapy and intermittent hemodialysis. It allows for a reduced ultrafiltration rate and prolonged treatment duration to maximize dialysis dose while maintaining hemodynamic stability. The document outlines the indications for SLEDD, including patients at risk of disequilibrium or with borderline cardiovascular stability. Preliminary studies suggest SLEDD is a safe and effective option for AKI patients otherwise unsuitable for standard therapies.
Dialysis disequilibrium syndrome (DDS) is characterized by neurological symptoms that occur during or after dialysis as a result of a rapid shift in osmoles like urea. It is caused by a transient osmotic gradient between plasma and brain cells as urea is swiftly removed by dialysis, causing water to shift into neurons and produce cerebral edema. Risk factors include the first dialysis treatment or high pre-dialysis BUN. Symptoms range from mild like headache to severe like seizures. Prevention focuses on limiting urea removal during initial sessions by using lower blood and dialysate flows with sodium modeling. Treatment is usually supportive and symptoms resolve within 24 hours.
The patient is a 49-year-old woman with end-stage renal disease and diabetes who presented with altered mental status. She receives hemodialysis three times per week for a few years. Recently, she has been increasingly tired, weak, and unable to perform daily activities with poor appetite and nausea. On examination, she was pale and swollen with low hemoglobin. Tests found elevated creatinine, BUN, and electrolyte abnormalities. The most probable diagnosis is inadequate hemodialysis, as her symptoms and labs are consistent with worsening uremia due to insufficient solute clearance from her dialysis sessions. Kt/V is a measure of dialysis adequacy that accounts for urea clearance and patient
The document discusses various complications that can occur during hemodialysis treatment including intradialytic hypotension, dialyzer reactions, disequilibrium syndrome, cramping, air embolism, hemolysis, cardiac arrhythmias, hemorrhage, pruritus, febrile reactions, hypokalemia, hyperkalemia, and dialysis pericarditis. It describes the etiology, diagnosis, and treatment approaches for each complication.
This document discusses hepatitis B virus (HBV) infection in patients undergoing dialysis or kidney transplantation. Some key points:
1) HBV infection is a concern for dialysis and transplant patients due to their immunosuppressed state, which increases susceptibility to infection and can cause HBV to take a more severe clinical course.
2) While HBV infection may seem relatively mild in dialysis patients, it poses significant risks if they undergo kidney transplantation, as HBV can reactivate or cause life-threatening complications after transplant.
3) Preventing HBV transmission in dialysis units is important through measures like vaccination, protective equipment, and regular screening. Prophylactic treatment is recommended for infected patients considering transplant
Role of erythropoitin in chronic kidney diseaseAftab Siddiqui
1) Erythropoietin (EPO) and novel EPO stimulating proteins (NESPs) play an important role in managing anemia in chronic kidney disease (CKD). EPO therapy aims to increase hemoglobin levels by 1-2 g/dl per month and reduce need for blood transfusions.
2) Intravenous or subcutaneous iron supplementation is also important to manage iron deficiency and allow effective response to EPO. The target is to achieve transferrin saturation between 20-50% and serum ferritin above 100 ng/ml.
3) Causes of resistance to EPO action include iron, folate or carnitine deficiencies, chronic infections, inflammation, and secondary hyperpar
Anemia is a common complication of chronic kidney disease that can cause fatigue. While the kidneys normally produce erythropoietin to stimulate red blood cell production, CKD patients have relative erythropoietin deficiency. This leads to anemia which, if left untreated, can negatively impact quality of life and cardiovascular health. Erythropoiesis-stimulating agents and iron supplementation are used to treat anemia in CKD, though the appropriate hemoglobin target level remains an area of ongoing research and debate given risks identified with higher targets in some studies.
The document discusses acute kidney injury (AKI), defining it, outlining causes and types including prerenal, intrinsic renal and postrenal, describing evaluation through investigations and clinical assessment, prevention and management recommendations including dialysis interventions, and complications of AKI.
This document discusses the management of anemia in chronic kidney disease (CKD). It begins by defining anemia and its causes in CKD, which include reduced erythropoietin production and decreased red blood cell survival due to kidney failure. Left untreated, anemia in CKD can lead to deterioration in cardiac function, impaired cognition, and increased fatigue and mortality risk. The main therapeutic options for treating anemia in CKD are red blood cell transfusions, androgens, and erythropoiesis-stimulating agents (ESAs). ESAs such as epoetin alfa and darbepoetin alfa are now the standard treatment as they reduce transfusion needs and risks while helping to mobilize
This document discusses exit site infections in peritoneal dialysis patients. It defines acute and chronic exit site infections and notes that approximately one fifth of peritonitis episodes are associated with exit or tunnel infections. Exit site infections are commonly caused by Staphylococcus aureus or Gram-negative bacteria like Pseudomonas. Treatment depends on the severity and causative organism but may include antibiotics, changing the exit site dressing, or catheter removal in severe cases. Preventing exit site infections through good catheter care and possibly antibiotic prophylaxis can help reduce risks of peritonitis and catheter loss.
This document discusses hyperphosphatemia, which occurs when phosphate levels in the blood are abnormally high. It provides information on the causes of hyperphosphatemia, which include kidney disease, and discusses guideline target levels and treatment options. Treatment involves phosphate restriction, phosphate binders such as aluminum hydroxide, calcium salts, and newer non-calcium binders. Novel therapies being researched include nicotinamide and iron-based compounds. The goal is to manage phosphate levels through diet, medication and dialysis to prevent complications in patients with chronic kidney disease.
The document summarizes potential complications of peritoneal dialysis catheters including malfunctioning catheters, early and late non-functioning, and causes such as constipation, intra-abdominal adhesions from previous surgery or peritonitis, catheter migration, blood or fibrin blocking the catheter, and hernias. It describes methods for investigating malfunctioning catheters including abdominal x-rays, x-rays with contrast dye, and CT scans. It provides guidance on managing different causes through measures like laxatives, re-siting the catheter, adding heparin to dialysate, or removing the catheter.
Catheter related infections atmeda final (1)FarragBahbah
This document discusses catheter-related infections in hemodialysis patients. It covers definitions of different types of infections, pathogenesis, epidemiology, diagnosis, treatment, and prevention strategies. The most common causative pathogens are coagulase-negative staphylococci, S. aureus, enterococci, and Candida species. Antibiotic lock solutions can be used to reduce infections and allow catheter salvage in some cases. Strict adherence to infection control practices and prioritizing arteriovenous fistulas can help reduce catheter-related infections.
The document discusses complications of peritoneal dialysis, specifically peritonitis. It describes the typical presentation of peritonitis as abdominal pain and cloudy dialysate fluid. Causes include breaks in sterile technique or recent infections. Diagnosis requires abdominal pain and cloudy fluid with leukocytosis. Treatment involves empiric antibiotics targeting gram positive and negative organisms. Outcomes depend on causative organisms and whether the peritoneal catheter is infected.
IMMUNODEFICIENCY DISORDERS GROUP 6A.pptxYvonneMwita
This document discusses immunodeficiency diseases. It defines immunodeficiency as a state where the immune system's ability to fight infections is compromised or absent. There are two types: primary immunodeficiency which is inherited and diagnosed in childhood, and secondary immunodeficiency which is acquired from diseases or environmental factors like HIV. Primary immunodeficiencies are classified into humoral deficiencies, cellular deficiencies, combined deficiencies, complement disorders, and phagocytosis disorders. Examples like X-linked agammaglobulinemia and common variable immunodeficiency are described. Nursing management focuses on infection assessment, patient teaching, and supportive care.
This document discusses various biologic therapies used to treat kidney diseases. It defines biologics as substances derived from biological sources using biotechnology. Biologics are classified into categories including hormones, growth factors, cytokines, vaccines, enzymes and antibodies. Specific biologics discussed that target the immune system include monoclonal antibodies against TNFα, IL-2, IL-6, CD20, C5, VEGF, and TWEAK. Conditions where biologics may be used include glomerular diseases, transplantation, lupus nephritis, ANCA-associated vasculitis, and hepatitis C infection. Potential benefits and risks of different biologics are presented.
Induction immunosuppression refers to potent immunosuppressive therapy used in the peritransplant and immediate posttransplant periods to deplete or modulate lymphocytes. The document discusses various induction agents including polyclonal antibodies (ATG), monoclonal antibodies (basiliximab, daclizumab), and alemtuzumab. ATG is derived from rabbits or horses immunized with human cells and contains antibodies against T cell markers. It causes prolonged depletion of T cells. Basiliximab blocks the IL-2 receptor on activated T cells. Studies show ATG reduces rejection rates compared to no induction, while IL-2RA induction has fewer adverse effects than ATG. Induction therapy is recommended routinely by guidelines, with
A presentation detailing the symptoms, pathogenicity, factors affecting, diagnosis and treatment of the autoimmune disorder systemic lupus erythematosus
1. A secondary immune response occurs upon reexposure to an antigen and results in a faster and stronger response than the primary response due to memory cells.
2. The secondary response has a very short or negligible lag phase and the antibody concentration increases much more rapidly than in the primary response, reaching levels 100-1000 times higher.
3. Memory B and T cells generated during a primary response enable a rapid secondary response through faster activation, greater sensitivity, and production of more effective antibodies.
This document discusses immunopotentiation and immunosuppression. It describes three ways to potentiate the immune system: vaccination, adjuvants, and lymphokines. Adjuvants work by affecting antigen presentation or stimulating macrophages. Common adjuvants include Freund's incomplete adjuvant, liposomes, muramyldipeptide, levamisole, and isoprinosine. Lymphokines that can be used include interferons and interleukins. The document also discusses general immunosuppression therapies like cytotoxic agents, glucocorticoids, cyclosporine, tacrolimus, and rapamycin, as well as specific therapies such as monoclonal antibodies and blocking co-stimulatory signals to induce T cell anergy
Based on the information provided, the most likely diagnosis is:
Behçet's disease.
Key characteristics that support this diagnosis include:
- Recurring rash on the face, arms and hands. Rash is a common manifestation of Behçet's disease.
- Painless mouth ulcers. Oral ulcers are a hallmark feature seen in over 90% of patients with Behçet's disease.
- No other medical conditions reported. Behçet's disease typically presents in otherwise healthy young adults.
- Sexual activity mentioned. Behçet's disease has been associated with sexual transmission in some cases.
Other conditions that can cause mouth ul
This document discusses various non-steroidal immunosuppressant drugs used to treat non-infectious uveitis. It describes corticosteroid-sparing immunomodulatory therapy as necessary for patients who require high corticosteroid doses or have intolerances. The document categorizes immunomodulatory options and provides details on mechanisms of action, dosing regimens, and side effects of common agents including antimetabolites, calcineurin inhibitors, cytotoxic drugs, and biologic response modifiers.
Covid 19 advancement in treatment over timeDR.pankaj omar
This document discusses various aspects of diagnosing and treating COVID-19, including:
1. The timing of initiating antiviral, anti-inflammatory, and anticoagulant treatments is important, with antivirals recommended early in symptomatic phase and steroids in pulmonary phase.
2. Remdesivir has been shown to shorten recovery time in moderately ill hospitalized patients. Tocilizumab was not effective at preventing intubation or death.
3. Treatment protocols for mild, moderate, and severe COVID-19 cases are outlined, recommending medications, supplements, and monitoring based on disease severity and stage.
This document discusses potential new drugs for inflammatory bowel disease (IBD) beyond current biological therapies. It outlines several therapeutic pipelines targeting cytokines like TNF, IL-12/IL-23, IL-13 and IL-6. Anti-adhesion molecules targeting integrins and MadCAM-1 are also discussed. The document explores manipulating the microbiome through probiotics, antibiotics or fecal transplantation, as well as using prognostic genomics to predict treatment responses. Overall it concludes that future IBD treatment will be personalized based on biomarkers and tissue signatures to select therapies beyond TNF blockers.
Mesenchymal stem cells have immunomodulatory properties and may provide benefits in kidney transplantation. A randomized controlled trial compared induction therapy with autologous mesenchymal stem cells to anti-IL-2 receptor antibody induction in living-related kidney transplant recipients. Patients receiving mesenchymal stem cells had lower rates of acute rejection and opportunistic infection within the first year, as well as better kidney function. No safety issues or compromises in graft survival were observed with mesenchymal stem cell treatment.
1) Liver transplantation was first performed in dogs in 1955 and in humans in 1963, with the first successful liver transplant occurring in 1967. Survival rates for liver transplants are now around 90-95% after one year and 70% after five years.
2) The liver is considered the least immunogenic organ due to factors such as a lack of suitable antigen presenting cells and different HLA molecule expression. It requires less immunosuppression than other transplanted organs.
3) Immunosuppression protocols for liver transplantation aim to prevent rejection through induction therapy in the early period and maintenance therapy long-term using calcineurin inhibitors, mTOR inhibitors, antiproliferatives, and corticosteroids.
The document discusses the pathogenesis of lupus nephritis, including the loss of immune tolerance leading to autovaccination and persistent antinuclear antibodies, with a subset of patients developing lupus nephritis depending on additional genetic susceptibility factors; it also covers the classification, treatment approaches including immunosuppressive therapies, and clinical trials of lupus nephritis.
Immunostimulators are prescribed to enhance the immune response against infectious diseases, tumours, primary or secondary immunodeficiency, and alterations in antibody transfer, among others .
This document discusses primary and secondary immunodeficiencies. It defines primary immunodeficiency as genetic or developmental defects of the immune system, which are classified as lymphoid or myeloid. Examples of lymphoid immunodeficiencies include SCID and XLA. Myeloid immunodeficiencies affect innate immunity and include chronic granulomatous disease. Secondary immunodeficiency is acquired through exposure to agents like HIV, which causes AIDS by infecting and destroying CD4+ T cells. Experimental models to study immunodeficiencies include nude and SCID mice with genetic mutations.
Primary combined antibody and cellular immunodeficienciesSai Hari
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2. Outline of presentation
1. Why vaccination is needed in CKD
2. Link Between CKD and Immunity
3. Effect of Kidney function on Immune Deregulation
4. Causes of impaired immunity in renal failure
5. Effect of Chronic Kidney Disease on Immune Systems
6. Alterations of the immune system in end-stage renal disease
7. Vaccination and immunity in end-stage renal disease
8. Guidelines for vaccination in patients with chronic kidney disease
9. Potential Methods for Improving Vaccine Efficacy
3. Why vaccination is needed in CKD
• Vaccines help protect people
from diseases caused by
infections from certain germs
(viruses or bacteria).
• People haveing CKD have a
higher chance of being
seriously ill from these
diseases, so they especially
need protection.
6. Causes of impaired immunity in renal
failure
1. Disruption of Mucocutaneous Barriers and Granulocyte
Dysfunction
2. Cell-Mediated Immunity
3. Humoral Immunity
4. Immunosuppressive Medications
7. 1. Disruption of Mucocutaneous Barriers
and Granulocyte Dysfunction
• Chronic renal insufficiency is associated with numerous structural
and chemical mucocutaneous abnormalities which alter nasal and
cutaneous flora and diminish resistance to penetration by
microorganisms.
• Barriers are also disrupted at mucous membrane interfaces by
impaired mucociliary and alveolar macrophage clearance
mechanisms, gastrointestinal tract ulcerations and impaired urinary
drainage and concentrating defects.
• Defences against infectious agents transgressing these barriers are
further impaired by granulocyte dysfunction, which is characterised
by reduced adherence, mobility, chemotaxis, phagocytosis and
intracellular bactericidal activity.
8. 2. Cell-Mediated Immunity
• The immunodeficiency observed in renal insufficiency is primarily
due to impairment of cell mediated immunity.
• The basic defect appears to involve intrinsically normal cellular
elements bathed in a suppressive host milieu, as it can be reversed
by washing and resuspending uremic lymphocytes in normal serum.
• There is depressed activation and proliferation of T lymphocytes
resulting in lymphopenia and a reduced absolute, but not relative,
number of peripheral blood T lymphocytes.
9. • The in vitro lymphocyte abnormalities include reduced mitogen-
induced blastogenesis impaired Iymphokine production, suppressed
antibody dependent cell-mediated cytotoxicity, enhanced expression
of interleukin-2 (IL-2) receptors, increased sensitivity of lymphocytes
to the suppressive effect of glucocorticoid and enhanced suppressor
cell activity.
• The in vivo correlates of impaired cell-mediated immunity in chronic
renal failure include cutaneous prolonged survival of skin allografts,
increased incidence of neoplasms (up to 7 times the expected rate)
and frequent infections. The incidence of tuberculosis is increased
by up to 10 to 12 fold. There is also a significantly increased
incidence of fungal and viral infections.
2. Cell-Mediated Immunity
10. 3. Humoral Immunity
• Uremic patients can synthesise normal quantities of immunoglobulin
despite reduced B lymphocyte counts.
• Some investigators have found that depression of certain
immunoglobulin G (IgG) subclass antibody responses occurs
following vaccination. This may account in part for the poor
protective efficacy of vaccines.
• The uremic environment causes defective macrophage functioning
Reduced interleukin-1 (IL-I) production by monocyte-macrophages
results in diminished IL-2 production by T lymphocytes. This in turn
leads to impaired generation of activated antigen-specific T helper
cells required for adequate B cell antibody synthesis and ultimately
for optimal vaccine-induced seroconversion.
11. Schematic representation of impaired cellular interactions involved in
impaired vaccine antibody response in patients with renal disease. IL (-I, -
2, -4, -6) are interleukins; + = a stimulatory effect; - = an inhibitory effect.
12. 4. Immunosuppressive Medications
• The immunosuppressive medications used to prevent renal
transplant rejection impair cell mediated and humoral immune
responses to both infectious agents and vaccines.
• Glucocorticoids suppress the release of IL-l by the monocyte-
macrophage system and, in large doses, induce lymphopenia by
sequestration of recirculating blood lymphocytes to lymphoid tissue.
Azathioprine inhibits the synthesis of DNA and RNA, thereby
suppressing lymphocyte proliferation.
• Cyclosporine appears to have a preferential effect upon early
activation of helper-inducer T lymphocytes through blockage of IL-2
production.
13. Effect of Chronic Kidney Disease on
Immune Systems
CKD affects both major immune systems: Innate and Adaptive
responses.
A. Innate immune system:-
• The innate immunity includes recognition, phagocytosis, digestion of
pathogens, development of inflammation, and presentation of
antigens.
• Innate immune recognition is characterized by specific pathogen-
associated molecular pattern (PAMP).
• PAMP receptors are expressed on effector cells–macrophages as
well as dendritic APCs.
• These receptors are of three types:
1. Secreted
2. Endocytic
3. Signaling
14. • Secreted pattern-recognition molecules function by opsonization,
recognition by the mannose-binding lectin complement pathways
and phagocytosis.
• Endocytic pattern-recognition receptors present on the surface of
phagocytes recognize PAMPs on a microbial wall and mediate
uptake of pathogens into lysosomes leading to destruction of
pathogens.
• Signaling pattern recognition acts through expression of toll-like
receptor family leading to cytokine release and inflammatory
response.
Effect of Chronic Kidney Disease on
Immune Systems
16. B. Adaptive immune system
• Begins with antigen presentation.
• The processed antigens bind to the major histocompatibility complex
(MHC) molecules on the APC sactivate naive T cells, converting
them into functional cells.
• In addition to signaling by the peptide-MHC molecule complex, a
costimulatory signal through CD80–CD86 interaction is also
necessary.
• After binding to specific foreign antigens, B lymphocytes are
converted into plasmacytes that produce antibodies.
Effect of Chronic Kidney Disease on
Immune Systems
18. Alterations of the immune system in End
Stage Renal Disease
• ESRD is associated with a variety of changes in the immune system:
Both anti-inflammatory interleukin (IL-10) and proinflammatory
cytokines tumor necrosis factor-α (TNF-α, IL-6) are increased.
• Cytokine accumulation occurs as a result of poor renal clearance
and increased production.
• All three classes of PAMP receptors are affected by ESRD.
• T-cell proliferation is decreased in the uremia.
• Th1 cells produce TNF-α, IL-12, and interferon-γ
• Th2 cells produce IL-4 and IL-5
• Th1 lymphocytes activate macrophages and neutrophils
• Th2 cells promote humoral immunity
19. Vaccination and immunity in End Stage
Renal Disease
• The reduced response to vaccination in ESRD patients is generally
related to alterations of T lymphocyte function.
• Compared to general population, patients on dialysis have lower
antibody titers.
• Disturbances in T lymphocytes and antigen-presenting cells
function are thought to mediate this malfunction.
• In a study of 32 peritoneal dialysis (PD) patients who received
hepatitis B vaccine, the weekly Kt/V was better in seroconverters
than that in nonconverters (2.37 vs. 2.01).
20. Guidelines for vaccination in patients
with chronic kidney disease
• By virtue of their immunosuppressive state, chronic kidney
disease (CKD) patients are at risk for many infections, some of
which are vaccine preventable.
• Knowledge of vaccination is imperative to treat CKD patients
effectively.
21. Hepatitis B Vaccine
• Hepatitis B vaccination is recommended for all CKD patients.
Rationale:
• The prevalence and incidence of the hepatitis B infections are high,
at about 7.6% and 3.2%, respectively among dialysis patients in
India.
• Vaccine provides effective protection against the infection.
Vaccination in early stages of CKD has better seroconversion rate
than late vaccination.
Dosage and schedule:
• Higher vaccine dosages or an increased number of doses are
recommended for subjects with CKD (eGFR <30 ml/min).
• Patients should receive four doses of hepatitis B vaccine as early in
the course of disease as possible.
• Recombinant hepatitis B vaccine is recommended.
22. • Use special formulations of vaccine (40 mcg/ml) or two 1 ml 20 mcg
doses given at one site. Dose schedule should be 0, 1, 2, and 6
months.
• Vaccine should be given intramuscularin deltoid regions.
• Assess antibody titer to hep B surface antigen (anti-HBs).
• First titer should be done 1–2 months after the primary course is
completed and annually thereafter.
• Booster dose should be given if anti-HBs titer falls below 10 mU/ml.
• Revaccination with full doses is recommended for persons who do
not develop protective antibody titer after primary course.
Hepatitis B Vaccine
23. Hepatitis B Vaccine
Hepatitis B serologic testing and surveillance in in-center patients on
hemodialysis. Anti-HB, antibody to hepatitis B surface antigen; HBsAg, hepatitis
B surface antigen; HBV, Hepatitis B virus; NEG, negative; POS, positive
24. Pneumococcal Vaccine
Dosage and schedule:
• CKD patients over the age of 19 should receive a dose of
pneumococcal conjugate vaccine-13 (PCV13) first, followed by a
dose of valent pneumococcal polysaccharide vaccine 23 (PPSV23)
at least 8 weeks later.
• Subsequent doses of PPSV23 should follow current PPSV23
recommendations for adults at high risk.
• Specifically, the second PPSV23 dose is recommended 5 years
after the first PPSV23 dose for persons aged 19–64 years.
• pneumococcal vaccination should be administered to all patients
with CKD as early in the disease as possible.
• The ACIP schedule recommends a PCV13 prime vaccination
followed by a PPV23 vaccination.
25. Vaccination schedule for prevention of pneumococcal disease.
PCV13, 13-valent pneumococcal conjugate vaccine; PPSV23,
23-valent pneumococcal polysaccharide vaccine.
Pneumococcal Vaccine
26. Influenza vaccine
Rationale:
• Dialysis patients are at increased risk of influenza-related mortality.
Four-fold increase in serum antibody titer against influenza antigens
have been observed in 50% of dialysis patients compared to 40%
healthy controls, and no systemic reactions have been reported
following influenza vaccination in dialysis patients.
Dosage and schedule:
• Influenza vaccine should be given annually before the beginning of
the influenza season for persons 6 months of age or older on
dialysis.
• The vaccine dose is 0.25 ml by intramuscular route for those
between the ages of 6 and 35 months, and 0.5 ml thereafter.
27. • To those <9 years of age, 2 doses of influenza vaccine are
administered at least 1 month apart and at 9–12 years, one dose of
split virus vaccine should be given. After the age of 12 years, one
dose of whole or split virus vaccine should be given.
Influenza vaccine
28. Recommendations regarding other
routine vaccines
A. Live attenuated vaccines:
Rationale:
• There is high risk of complications and death associated with
chicken pox infection in adulthood. About 85% of children on dialysis
develop protective antibody levels within 6 months following single
dose of vaccine. Varicella vaccine has been reported to be safe for
children on dialysis.
• Seroconversion rate following measles, mumps, and rubella
vaccine (MMR Vaccine) for all 3 antigens is approximately 30%, for
mumps alone 50%, and for measles and rubella combined 80%.
Patients on dialysis should be tested for seroconversion.
29. • Live vaccines are contraindicated in immunocompromised patients
due to risk of vaccine-induced infections. Even though the limited
number of studies in CKD patients has not shown any adverse
reactions, these vaccines should be avoided, with the exception of
varicella and MMR vaccines.
Dosage and schedule:
• Children 1 year of age or older should receive 1 dose of
subcutaneous varicella vaccine.
• Adolescents and adults should receive 2 doses of 0.5 ml
subcutaneously, with second injection at least 4 weeks after the first.
• MMR vaccine should be given to all children including those on
dialysis between 12 and 15 months of age with a booster dose
between 4 and 6 years of age.
Recommendations regarding other
routine vaccines
30. Recommendations regarding other
routine vaccines
B. Inactivated vaccine and toxoids:
• All inactivated vaccine and toxoids are safe and effective when used
in dialysis patients and should be administered to children and
adults on chronic dialysis using the same doses and schedules
recommended for immunocompetent persons.
• Haemophilus influenzae Type B conjugate vaccine
(HiB) HiB vaccine is safe and should be given to children beginning
at 2 months to 5 years of age using same dosage and schedule
used for healthy children and adults. A study of children on chronic
ambulatory peritoneal disease (CAPD) has shown seroconversion
rate of 90%.
31. Diphtheria and tetanus toxoids and pertussis vaccine
• Children on dialysis should receive vaccine as recommended for
healthy children.
• The vaccine is well tolerated by dialysis patients. The persistence of
immunity in patients on dialysis is comparable to that among healthy
persons.
Hepatitis A vaccine
• Hepatitis A vaccine is highly immunogenic in children, adolescents,
and adults, with up to 100% of recipients develop protective level of
antibodies > 20 mU/ml persisting for up 48 months.
Recommendations regarding other
routine vaccines
32. Staphylococcus aureus vaccine:
• Patients on dialysis are at high-risk of S. aureus infection.
• Study data suggest that ESRD patients had an impaired
immunological response to S. aureus vaccination, in comparison to
that of the healthy controls, and showed 50% reduction of IgG levels
6 months after a 25-μg vaccination with a monovalent conjugated S.
aureus type 5 capsular polysaccharide.
• In another study, a single injection of a bivalent conjugate vaccine
containing S. aureus type 5 and 8 capsular polysaccharide 25 μg of
each capsular polysaccharide also showed only partial and short-
lived protection in ESRD patients. The study was declared as failure
study as the decrease in vaccine efficacy occurred after 40 weeks.
Recommendations regarding other
routine vaccines
33. • To prolong the efficacy of the vaccine, a higher dose of the same
vaccine (100 μg of each capsular polysaccharide) was tested in
ESRD patients in comparison to placebo.
• The vaccine was efficient and well tolerated in comparison to
placebo during the study period. However, the incidence of S.
aureus bacteremias was not statistically different from placebo after
50 weeks.
Recommendations regarding other
routine vaccines
34. Potential Methods for Improving Vaccine
Efficacy
• Concomitant use of adjuvant immunomodulators .
• The simultaneous administration of low doses of IL-2 with HBV
vaccine normalised the deficient immune response to the vaccine in
hemodialysis patients.
• IL-2 production can also be stimulated by thymopentin, a penta-
peptide component of thymopoietin
• Two studies showed modest enhancement of antiHBs responses by
the administration of thymopentin in haemodialysis patients
following HBV vaccination, but 4 other trials failed to demonstrate
any beneficial effect.
35. Refrences
1. 2016 Indian Journal of Nephrology l Published by Wolters Kluwer –
Medknow, Indian Society of Nephrology Guidelines for Vaccination
in Chronic Kidney Disease
2. Snigdha Reddy, Chandrika Chitturi et al, Vaccination in Chronic
Kidney Disease, Adv Chronic Kidney Dis. 2019;26(1):72-78
3. The Use of Vaccines in Renal Failure, CLINICAL
PHARMACOKINETICS AND DISEASE PROCESSES, David W
Johnson and Simon J. Fleming, Department of Renal Medicine,
Royal Brisbane Hospital, Brisbane, Queensland, Australia..
4. Maaz Syed-Ahmed and Mohanram Narayanan, Immune
Dysfunction and Risk of Infection in Chronic Kidney Disease, Adv
Chronic Kidney Dis. 2019;26(1):8-15