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Kidney Int. 2021 Mar;99(3):559-569.
doi: 10.1016/j.kint.2020.10.026.
Executive summary of the KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease
Alfred K Cheung 1, Tara I Chang 2, William C Cushman 3, Susan L Furth 4, Fan Fan Hou 5, Joachim H Ix 6, Gregory A Knoll 7, Paul Muntner 8, Roberto Pecoits-Filho 9, Mark J Sarnak 10, Sheldon W Tobe 11, Charles R V Tomson 12, Lyubov Lytvyn 13, Jonathan C Craig 14, David J Tunnicliffe 15, Martin Howell 15, Marcello Tonelli 16, Michael Cheung 17, Amy Earley 17, Johannes F E Mann 18
PMID: 33637203
KDIGO Website with links to
Full Guideline document
Data Supplement
Top 10 Takeaways
Point-Counterpoint
Introduction
KDIGO have updated their blood pressure guidelines for patients with CKD. Don’t be fooled into thinking it is all about the new target number of 120 mmHg systolic – the devil is in the detail, and the wake-up call for many will be to consider how we measure blood pressure in adult outpatients, rather than the new target itself. The 2021 KDIGO guideline is around 80 pages long - read on for a summary of the controversial points, with a focus on the key updates (for example, we won’t deep dive recommendations that exercise is a good thing).
Background
“The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try to reduce it.” J.H. Hay, 1931
We’ve come a long way since the medical consensus in the early 20th century that blood pressures up to 210/110 mmHg were “benign hypertension that need not be treated” (Diseases of the Heart, Charles Friedberg, 1949).
But what BP should we be targeting in our patients with CKD? How low should we go? Nephrology has been stung by aiming for ‘normal values’ before - just think of the increase in severe adverse events when goal haemoglobin of 13.5g/dL was achieved using ESAs to treat renal anaemia in CHOIR (Singh et al, NEJM 2006), to name but one example.
The 2012 KDIGO CKD guideline recommended targeting ≤140/90 mmHg, unless albuminuria was present (defined as urine ACR >3mg/mmol), in which case the goal was ≤130/80. This distinction based on the pivot-point of albuminuria quantification is well-supported by meta-analysis including the large AASK and MDRD (2010) trials, which consistently showed a lower BP target to be beneficial in their proteinuric subgroups.
But the evidence has continued to evolve – most notably since the 2012 KDIGO guideline, the Systolic Blood Pressure Interventional Trial (Wright et al, 2015; NephJC Summary) has been published and dissected, and heavily informs this guideline now, as it informed the 2017 AHA/ACC guideline (NephJC Summary).
Methods
The guideline is presented in five chapters, with the major updates being in Chapter 1 ‘Blood pressure measurement’ and Chapter 3 ‘Blood pressure management in patients with CKD, with or without diabetes, not receiving dialysis’ - issues which are inherently intertwined. Chapter 2 says encourage patients to eat less salt and exercise more – important, but somewhat less controversial. Chapter 4 presents separate recommendations for patients with a kidney transplant. Chapter 5 relates to the paediatric population with CKD.
NephJC has previously recapped the difference between ‘practice points’ and ‘recommendations’ when the 2020 KDIGO diabetes guidelines were discussed – essentially practice points are consensus statements based on expert judgement that may be based on limited evidence, whereas recommendations are based on evidence categorised using the well-known GRADE methodology (Guyatt, BMJ 2008). We will highlight which is which as we go through.
Workgroup
The KDIGO work group consisted of multi-disciplinary international experts. Many of these experts have funding declarations from previous work with pharmaceutical companies, which are documented in the supplementary material. It is also worth noting that 5/13 KDIGO workgroup members had links to SPRINT, including being a SPRINT steering committee member, a sub-committee chair, a site PI and two site co-investigators.
In addition, there was an Evidence Review team, separate from the workgroup, which did the literature review and provided the evidence table for the experts. Typically, this group has no conflicts with industry.
Funding
KDIGO receives funding from many industries, see KDIGO Partners for full list. Ostensibly, the supporters are at arms length from the actual guideline development.
The guidelines
Like all KDIGO guidelines, the guidelines are presented as
Guideline statement
Key Information including
Balance of benefits and harms
Quality of Evidence
Values and Preference
Resource use and cost
Considerations for implementation
Rationale
Research Recommendations
It is useful to read beyond the guideline statement to some of these aspects. In particular, the ‘values and preference’ explain the target of 120 in almost all CKD, but 130 in transplant.
Headline updates
Recommendation 1.1: We recommend standardized office BP measurement in preference to routine office BP measurement for the management of high BP in adults (1B recommendation).
Recommendation 1.2: We suggest that out-of-office BP measurements with ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) be used to complement standardized office BP readings for the management of high BP (2B recommendation).
Recommendation 3.1.1: We suggest that adults with high BP and CKD be treated with a target systolic blood pressure (SBP) of <120 mmHg, when tolerated, using standardized office BP measurement (2B recommendation).
Practice Point 3.1.1: It is potentially hazardous to apply the recommended SBP target of <120 mmHg to BP measurements obtained in a non-standardized manner.
You can see what KDIGO picked out as the top 10 headline updates here.
In total there are:
Four 1B
One 1C
Two 2B
Four 2B recommendations, and
20 practice points.
It is unclear if as a field we would ever get to 1A recommendation as it would require a lot more, perhaps, unnecessary RCTs to address a similar question. It was good to see the absence of 2D recommendations, and they were likely turned into practice points, similar to the KDIGO-diabetes guidelines.
Chapter One
The key is how blood pressure is measured, and it is very important to note that the word “standardized” finds its way into all four key headline updates above.
In 2012 KDIGO made no recommendations on how to measure BP, citing that because almost all RCTs examining modification of BP in CKD had used office measurements the guideline could only make recommendations based on this method of assessment. However, it is well known that “non-standardized”, “routine”, or “casual” clinic BP readings show incredibly high variability. Whether it’s taking BP immediately after the patient has rushed in from a busy car park, or by placing the cuff below a rolled up shirt sleeve, many of these casual BP readings are inaccurate (to the point of being useless). Casual office BPs readings correlate poorly (see figure) with standardized BP measurements, both in patients with and without CKD, and this high variability means that there is no correction factor which can be applied to swap between them by calculation. Therefore, with more recent RCTs generating evidence based on standardized methods, KDIGO felt they should spell out exactly what we should be doing – so what do we mean by standardized anyway?
Figure from Agarwal, JAHA 2017. This shows poor correlation of standardized and routine office BP measurement in a population with CKD.
It is not about the equipment used in the clinic (whether manual auscultation or an automated oscillometric BP machine), but instead refers to the preparation and technique that goes into taking an accurate measurement. If you aren’t using this protocol then you are performing “casual office BP” and therefore cannot apply the <120 mmHg target outlined in Chapter 3.
So, before you start aiming for 120 mmHg, ask if this is what your clinic BP protocol looks like:
Modified from combination of KDIGO 2021 BP in CKD guideline and Whelton et al, 2017.
Consider that having a patient’s back unsupported may increase systolic BP by 5-15 mmHg, and that their bladder is full this may hike BP up by to 30 mmHg, and then you will begin to get a sense of the variability introduced in busy clinics taking causal measurements. Some of these factors are human error and fallibility, and an automated oscillometric device can eliminate them, but the other factors (patient position, behaviour, etc.) remain important to review and perform correctly. Hence the practice points that follow this recommendation state that:
Practice Point 1.1 An oscillometric BP device may be preferable to manual, though standardization emphasizes adequate preparation rather than the equipment, and,
Practice Point 1.2 An automated office BP (either attended or unattended) may be the preferred method of doing standardized BP measurement
KDIGO acknowledges that there is a higher burden in terms of patient and healthcare provider time by following this protocol, but they feel the benefits are worth it. In reality it is not overly resource-heavy, but will depend upon clinic time available, staff training, and institutional culture, which will vary between different centres. A guideline may be a good nudge to make the necessary culture changes. If one does not measure BP properly, what is one treating after all?
But I’m mostly relying on ambulatory BP and home BP monitoring, especially during the pandemic – where does this fit in?
Home BP measurements strongly predict long term adverse outcomes (Kario et al, Hypertension 2019), and KDIGO say will certainly complement standardized clinic readings. They are also useful to diagnose ‘white coat’ hypertension and ‘masked’ hypertension. It is also hoped that monitoring home BP encourages patient participation and adherence to their treatment. There is considerable agreement between home readings and ABPM.
However, out-of-office BP measurements were not what the trials of patients with CKD did, so therefore there is no RCT data looking at the benefits and harms of different target BPs using these techniques, and no hard outcome data which KDIGO can draw upon to guide care. Clearly, in the modern world of increasing telemedicine these trials assessing patient outcomes with different home BP targets are urgently needed. Hence the KDIGO workgroup provides a 2B guideline to suggest using ABPM and home BP to complement office BP for management. Notably, unlike the infamous AHA/ACC comparative table, the KDIGO workgroup recognizes that there is no scientific basis for suggesting a BP of, say, 160/90 in the office would correspond to precisely 145/90 for daytime ABPM or home BP and 140/85 for nighttime ABPM.
It is worth being aware that the same advice for taking reliable readings in outpatient clinics will also apply to patients monitoring their BP at home, so education about the same techniques should form part of our telemedicine clinic reviews. Some sources recommend that two measurements are taken before breakfast (and before medication), and another two are taken two hours after the evening meal, over a seven day period – then the results should be averaged, excluding the first day's readings.
Are you ready to implement this in your clinic? If so, why not now? KDIGO has put in prepared answers to address common concerns raised from reading the guideline, and make the point that we wouldn’t accept the same degree of inaccuracy in our measurement of creatinine, potassium, body weight or age, that we currently accept in our measurement of blood pressure.
Chapter Two
Next, KDIGO addresses lifestyle interventions for lowering BP in CKD patients. They state there is insufficient research conducted specifically in the CKD population to make recommendations about interventions such as weight loss in the obese patient or alcohol reduction in those who drink heavily – showing that they really don’t want to extrapolate from the general population, even when it comes to giving advice we all strongly believe is helpful for BP control!
Here’s our “TL;DR” summary of the chapter:
An important practice point (2.1.2) here is that the Dietary Approaches to Stop Hypertension (DASH)–type diet, or use of salt substitutes that are rich in potassium, may not be appropriate for patients with advanced CKD or those with hyporeninemic hypoaldosteronism or other causes of impaired potassium excretion, because of the potential for hyperkalemia.
Chapter Three
The <120 target
Aim at <120 mmHg systolic in patients with CKD, if using standardised clinic BP measurement techniques. There it is. It is easy to remember.
This does not include transplant patients (covered in Chapter 4) or dialysis patients (not covered at all). This new target removes distinctions based on degree of urinary protein, as previously the presence of proteinuria necessitated considering a lower BP goal. And normal practice isn’t changing in terms of the rate of getting the BP under control - the aim remains a slow and gradual decrease in BP over many months, giving time to react in those patients who struggle to tolerate the lower target.
So why has this changed from <130/80 in the 2012 KDIGO guideline? The answer mostly lies in SPRINT (though to a lesser degree some long term follow-up data from MDRD and AASK have also been supportive). The KDIGO recommendation for <120 mmHg target is given a quality of evidence at B status because it has altered largely based on one trial only (though, as they comment, albeit a high-quality RCT with CKD patients as a large pre-specified subgroup). It was given a strength of recommendation at 2, which carries a message that a risk/benefit discussion and attention from the clinician is mandatory (i.e. make sure blood pressure is measured the right way, ensure the patient is not too frail to benefit, etc.), rather than thoughtless implementation for all patients. It is hard to understand the rationale behind the KDIGO recommendations without reviewing SPRINT – also see the nephjc discussion or the renal fellow network summary.
Recall that SPRINT looked at patients at high cardiovascular risk, and compared targeting <120 or <140 mmHg systolic in 9361 patients over the age of 50. Results showed that the lower BP target led to improved survival (hazard ratio, 0.73; 95% CI, 0.60 to 0.90; P=0.003), lower rate of dementia, and fewer cardiovascular events (largely driven by a decrease in heart failure). It is worth noting that though they targeted <120 mmHg, the mean actually achieved was 121 mmHg, demonstrating that even within the rigours of a clinical trial actually meeting this goal is challenging. They included 2646 patients with CKD (with mean baseline eGFR 48 ml/min/1.73m2), making it the largest trial examining two different BP targets in this population. The CKD subgroup also showed a reduction in death and cardiovascular events.
There was a clinically non-significant faster rate of eGFR decline in the intensive treatment arm (-0.47 ml/min/1.73m2/year versus -0.32 ml/min/1.73m2), but lower albuminuria and no increase in urine biomarkers of tubular injury. It is emphasised that the benefit of targeting 120 instead of 140 mmHg is all about cardiovascular protection and NOT about renoprotection specifically. But more patients were alive in the intensive BP control group, and being alive remains generally important for kidney function too.
Surprisingly in SPRINT there was no increased incidence of falls, syncope or orthostatic hypotension in the sub-120 arm, though there were increased dyskalaemias. There was also more AKI in the lower BP target group, though mostly stage 1 AKI which showed full subsequent recovery. One must bear in mind the exclusion criteria in SPRINT, namely:
diabetes
eGFR <20 ml/min/1.73m2
history of stroke
severe hypertension (≥180 mmHg on 0-1 antihypertensives, ≥150 mmHg on 4 meds)
age <50
life expectancy <3 years
nursing home resident
proteinuria >1g/day
glomerulonephritis on immunosuppression
any organ transplant
Although SPRINT did not recruit those with diabetes, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial recruited exclusively patients with type 2 diabetes (though none with a serum creatinine >1.5 mg/dL), and demonstrated decreased risk of stroke when targeting systolic BP <120 mmHg versus <140 mmHg systolic (though not as a primary outcome).
So do KDIGO say the <120 mmHg target is for everyone?
Yes and no. They do recommend it for people with diabetes and CKD, which is different to other guideline recommendations. This is an extrapolation from a combination of analysis of SPRINT (including analysis of the CKD cohort and the pre-diabetes cohort) and ACCORD (which included only people with diabetes but no significant CKD). They highlight that there is less certainty in the context of diabetes, those at lower cardiovascular risk, those with BP 120-129 mmHg, the very frail and those with CKD Stage G4-5 – so quite a large proportion of patients in outpatient nephrology clinics! However, uncertainty does not necessarily mean lack of benefit, just lack of RCT data to support or refute. The major medical conditions that get a mention are carotid stenosis and very low diastolic BP, and the presence of either may make lower systolic BP targets unadvisable.
KDIGO also clearly emphasises that the decision should be individualised and in line with patient preference and acceptance of treatment burden (as with all decisions in medicine!). Clearly shared decision making is key here.
Why is the target lower than those proposed by the ACC/AHA guideline / European Society of Cardiology / European Society of Hypertension groups?
Again, the how of BP measurement cannot be overemphasised – standardized measurements are vital in the interpretation of the KDIGO BP targets, and differences here explain some of the target discrepancy:
A major concern from other guideline writers is that health practitioners might apply the <120 target to non-standardized BP readings. KDIGO also points out that this would be potentially hazardous, but believes we can understand the distinction. Do you feel that guidelines should be idealistic? Or is it wiser to recommend higher BP targets out of concern that poor implementation on the ground will occur? There is no correct answer for this.
KDIGO was not comfortable with ACC/AHA giving a table of conversions for BP measurements taken with a standardized clinic approach to be adjusted to ambulatory and home BP measurements, based on a population level outcomes approach. It felt that individual variability in BP taken by different techniques was too great, and didn’t think the evidence was strong for successfully estimating standardized BP using measurements taken by other techniques.
If you are still uncomfortable with the 120 target, here is the wiggle room afforded in the practice points:
Practice Point 3.1.1: It is potentially hazardous to apply the recommended SBP target of <120 mm Hg to BP measurements obtained in a non-standardized manner.
Practice Point 3.1.2: Clinicians can reasonably offer less intensive BP-lowering therapy in patients with very limited life expectancy or symptomatic postural hypotension.
“The rest” of Chapter 3
Is either the same as the 2012 guideline suggestions or much less controversial, so again is summarised in a “TL;DR” summary slide.
Note that the dosage up-titration suggested in the practice point can be different based on regulatory bodies of each practicing location. Here is the suggested formulary dosage used in the original SPRINT trial (though note that dose range may be different in other conditions, e.g. patients with HFrEF.)
Chapter Four
The difference in BP targets for kidney transplant patients are because:
they were excluded from participation from the large RCTs which showed benefit from targeting <120 mmHg systolic
the hypothetical concern that lower BP targets could affect the denervated transplant kidney more adversely, causing AKI events beyond the modest level seen with lower BP targets in SPRINT in the non-transplant population
the higher AKI and incident CKD (seen with SPRINT, but discounted given cardiovascular and mortality benefit) are more important in the transplant setting, where graft function is very precious
Regarding drug choice, a Cochrane review (Cross et al, Cochrane DSR 2009) showed evidence for increased graft survival with dihydropyridine CCBs (though the events rates were low in the trials), and “low certainty to very low certainty” evidence is also highlighted by KDIGO in support of ARBs, but not ACEi. Why ARBs and not ACEi, given that a previous systematic review did not report any benefit with these classes when grouped together (Hiremath et al Am J Transpl 2017)? Well, KDIGO did their own evidence review and synthesis, and from tables S34 and S35, you can see that ARBs do reduce graft loss (RR 0.35, 95% CI 0.15 - 0.84) unlike ACEi (RR 0.71, 95% CI 0.47 - 1.06). On the other hand, ACEi do reduce CV events (RR 0.23, 95% CI 0.07 - 0.74) unlike ARBs (RR 1.06, 95% CI 0.57 - 1.95). But since graft loss is considered important based on what patients consider important (Tong et al, SONG-Tx, Transpl 2018), ARBs make it to the preferred list over ACEi.
Clearly, other more important factors may also come into play when choosing drug class in this cohort, such as time since transplant, the presence of proteinuria, indications for specific therapy such as beta-blockers, or in women who wish to conceive.
Chapter five
KDIGO group has made efforts to suggest a few things on the management of blood pressure in children. In the 2012 guidelines, more emphasis was given on when to treat and how to treat the blood pressure, whereas the 2021 guideline has made sure to highlight the method which needs to be adopted in general. The evidence for the suggestion is poor (2C), and is mostly based on the ESCAPE trial (ESCAPE, NEJM 2009). The trial showed that lowering mean arterial blood pressure to <50th percentile for age, sex, and height in children with CKD by ABPM will probably benefit in slowing the progression of the kidney disease especially in some subgroups (eGFR <45 ml/min/1.73 m2, those with glomerular disorders and PCR > 1.5g/g), and have no greater risks of adverse events. The study was not powered to show mortality benefit, and the intensification of blood pressure control came at the cost of increased pill burden.
In comparison, the 2016 European guidelines promote the use of office BP recordings in children with CKD, with <75 percentile BP targets in comparison with children without CKD (<50th percentile if proteinuric). A study on CKiD cohort published in 2021 (Flynn et al, Ped Nephrol 2021) has shown achieving a clinic BP of < 90 percentile was associated with slower CKD progression in children with glomerular or non-glomerular CKD. The discussion on the risk-benefit of treating high blood pressure in different diseases like salt losing nephropathy or children with CKD who have cardiovascular end organ damage, has led to confusion rather than a conclusion. Although the ESCAPE trial did utilize ABPM (which is the current gold standard as per AHA scientific statement) for setting the target, how practical (cost, non-availability & inconvenience) that is to use routinely is still a question. As per the CKiD study, protocol-driven manual auscultatory BPs are non-inferior to ABPM, but no good RCT evidence exists.
Speaking of proper techniques for BP measurements, whether oscillometric devices or home BP measurements are equivalent to clinical auscultation techniques is unknown. A recent retrospective study (Hanevold et al, J Pediatrics 2020) concluded that neither automated office blood pressure nor manual office blood pressure confirm or exclude daytime ambulatory hypertension with confidence, and there is still an ongoing role for ABPM in the evaluation of hypertension in children. The KDIGO guidelines also highlight the challenges in applying targets to children with height <120 cms (in whom no normotensive ABPM data exists), and monitoring for side effects in children who are more prone for dehydration, hypotension and AKI.
The 2012 guideline had recommended ACEi/ARBs to treat children with CKD who are not on dialysis and are hypertensive, irrespective of proteinuria. The 2021 guideline has updated this to be only a practice point, as there is no direct trial evidence. The group warns about ACEi/ARB-associated hyperkalemia and fetal risks if used in pregnant women. Although, the KDIGO group still stands steady on the annual ABPM monitoring (which is non-realistic at many centers) plus 3-6 monthly standardized auscultatory office BP monitoring in children with CKD, they have been considerate in suggesting protocol-driven standardized manual auscultatory office BP as an alternative in children.
Discussion
In 2019 Eliud Kipchoge made headlines by being the first to run a marathon in less than 120 minutes, and now nephrology is SPRINTing sub-120 too.
The KDIGO guidelines are seen as the international standard, and may be followed much more widely than other previously updated guidelines which also endorse the 120 mmHg target in CKD (sorry Canada).
With the focus on ‘how low to go’, it is more useful to consider ‘why to go low’ as well. The main reason to go low, as explained by the KDIGO workgroup, and the subject of a previous NephMadness, is that BP lowering in CKD matters because CKD patients commonly die due to cardiovascular disease. Cardiovascular death is more common than progression to kidney failure for most CKD patients. Intensive BP lowering reduces that risk. Paradoxically, while the KDIGO chose a goal of < 120 for cardiovascular protection, the AHA/ACC and the European Society of Cardiology chose a higher target. Fancy monoclonals may reduce amyloid deposits, but the most effective way of reducing cognitive decline is intensive BP lowering (Hughes et al, JAMA 2020). Although the recommendation of <120 mmHg is based on RCTS which may not have included a lot of the patients we see in the nephrology clinic (mostly eGFR 20-59, non-diabetic), it is also heartening to know that the excluded group of patients with polycystic kidney disease already had surrogate outcomes of kidney benefit from achieving BP <110 mmHg systolic in the HALT Progression of Polycystic Kidney Disease trial (Schrier et al, NEJM 2014).
The evidence is clearly less strong for many patients, such as those with diabetes, and the evidence is absent for those with eGFR <20 ml/min/1.73m2, in whom many nephrologists would be nervous about applying these aggressive targets given the AKI signal in SPRINT. Even if the GFR decline is hemodynamic and not tubular injury, a higher creatinine and looming dialysis may seem more fearsome than longer term CV benefit, making shared decision making very important.
Depending on your perspective, there is excitement or disquiet at the idea of how many more patients with CKD will now be eligible for antihypertensives, when compared to the KDIGO 2012 recommendations. Under the previous guidelines 49.8% of patients with CKD in the USA were estimated to be eligible for BP-lowering treatment, which rises to 69.5% under the 2021 guidelines (Foti et al, 2021).
One could also justifiably ask why the focus is so firmly on the 120 number, when we know already that:
many patients eligible for RASi are not prescribed them, as per the Foti paper above
almost 50% of hypertensive Americans are not at a target BP of <140 mmHg (Nwankwo, 2013), let alone <120 mmHg
treatment concordance remains a huge problem in refractory hypertension clinics
patients with CKD require our urgent attention regarding SGLT2 inhibitor initiation to help prevent cardiovascular events (though there’s no reason why new BP targets cannot complement introduction of SGLT2 inhibitors, rather than distract from them)
Much is made of the ‘unattended’ BP in SPRINT by people unfamiliar with meticulous BP measurement in RCTs in general. The so-called unattended BP more closely approximates a properly done manual resting BP; and a follow up study from SPRINT demonstrated that the measured BP was similar regardless of attended status, and so was the patient outcome (Johnson et al, Hypertension 2018).
The real concern is whether the high internal validity of standardized BP measurements within the confines of a trial are applicable externally in the real world where we practice (and where clinicians have built up years of bad habits in BP measurement technique). But the standardized BP protocol is not so arduous that it is inaccessible, and it comes with the huge advantage of generating more meaningful numbers that clinicians can have increased confidence in actioning. Taking a blood pressure measurement in outpatient clinic only then to immediately distrust it because of the poor methodology used is highly illogical and does a disservice to our patients, who may be left confused and more anxious by this approach.
Gaining BP control is one of the few things we can do for our patients which has demonstrated mortality benefit in RCTs – as long as you realise that a “slap the cuff on their arm as the patient sits down” approach is not acceptable, then the evidence says there is a large amount of good that can be done by targeting <120 mmHg systolic. Is it time to aim high with the quality of measurements and aim low with the numbers?
Summary prepared by
Renal registrar, Newcastle Upon Tyne, UK
Clinical Fellow in Adult Nephrology,
University of Toronto, Canada
Nephrology Fellow, BWH/MGH, USA
NSMC Interns
Class of 2021