DIALYSIS TIMESNEWS & VIEWS FROM RRI

Volume 10, No. 5 November 2005

Inside…PRESORTEDSTANDARD

U.S. POSTAGE

PAIDLANSING, MI

PERMIT NO. 224

Dialysis for ARF in Developing Countries:Theory and Practice ...................................................1-2

New Evidence-Based Medicine Journal ...........................2

Global Transplant Conference to Lay Groundwork for New Clinical Practice Guideline................................3

2006 Conference On Dialysis Information/Program ....4-5

Renal-Friendly Holiday Eating ........................................6

CKD On Capitol Hill........................................................7

Renal Research Institute Update ...................................7

Renal Research Institute’s purpose is to improve outcomes in Dialysis patients through col-laborative research. This paper presents views of events in the Dialysis community from avariety of sources and information about our programs. We welcome your input.

To search past issues online, register to receive future issues, or submit articles or letters forpublication, visit www.renalresearch.com or e-mail dialysistimes@rriny.com.

Dr. M. K. Mani, Chief Nephrologist,Apollo Hospital, Chennai, India

Institutions treating ARF in India fallinto two major categories: the private sector,in which the patient pays all the expensesincurred upon him, and government hospi-tals, in which the state pays. In the privatesector, patients are managed more or less asin developed countries. Intermittent peri-toneal dialysis (IPD) is no longer in vogue.Most patients are maintained on haemodial-ysis (HD) till they recover. Some with unsta-ble circulation are kept on continuous renalreplacement therapies (CRRT). CAPD isused for some with long drawn out ARF inwhom it is felt that HD might further delayrecovery. Most government hospitals arestarved for funds. Places on HD are kept forpatients who have CRF and have relateddonors for transplantation, so that they willnot occupy the unit for long. Patients withCRF who are being investigated or who arewaiting for a donor to come forward fromwithin the family are kept on IPD until theirprogress to transplantation is assured. Theavailability of HD for ARF depends on the

number of CRF patients on HD awaitingtransplantation. If slots are available, ARF maybe treated on HD, but otherwise IPD is used.

Institutions in small towns may not haveprogrammes for CRF, and therefore maynot need to invest in artificial kidneys. ARFis treated with IPD in such centres. Thereare no reliable figures, but the sale of IPDcatheters in Tamil Nadu (population 65 mil-lion) is 1650 per month. Many of thesecatheters must be used for ARF. The mostfrequent causes of ARF in Tamil Nadu arevasomotor nephropathy secondary to gas-troenteritis, acute glomerulonephritis, anddrug induced ARF. The prospects for recov-ery are therefore excellent, and in my unitonly 28% of patients needed dialysis.Mortality was just 12%, and 79% of all ARFmade a smooth and complete recovery.Apollo has a very active cardiothoracic surgicalunit, and one can assume that the proportioncaused by these simple causes will be evenmore in secondary care hospitals, with bettersurvival and even less need for dialysis.When dialysing for ARF, the goal is just tokeep the patient alive until his kidneys recover.

A study from Tirunelveli demonstrated that,in 40 patients with vasomotor nephropathysecondary to diarrhoea allocated at randomto either IPD or HD (20 in each limb), olig-uria lasted three and a half days in patientson IPD against six days on HD, and recoveryfrom renal failure occurred in 16 days onIPD against 20 days on HD. The absence ofHD does not adversely affect the outcome inthe majority of ARF in India outside ametropolis.

Our aim is to make dialysis as cheap aspossible without compromising efficiency. Afew studies have demonstrated that the effi-ciency of IPD can be increased by the addi-tion of sodium nitroprusside to the dialysate,to dilate peritoneal vessels. For some reasonthis has not caught on, though sodium nitro-prusside is available.

Studies in my own unit have establishedthat one hour one litre cycles are the mosteconomical for IPD, and that is now thenorm in most parts of the country. one hourone liter cycles achieve the same urearemoval as half hour cycles with one, oneand a half or two litre exchanges using 70%

Dialysis for ARF in Developing Countries: Theory and Practice

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DIALYSIS TIMESPage 2

as much dialysis f luid, and as one hour twolitre cycles using 75% as much. We have alsoshown that ARF with severe acidosis can betackled by adding 7.5% NaHCO3 to theIPD f luid. This is a useful addition to thearmamentarium of a unit that lacks facilitiesfor HD. Patients with ARF and acidosis(mean arterial pH 7.265, SD 0.054) wereallocated to either standard IPD with theacetate dialysate then in use, or to dialysiswith the same solution with 50 ml 7.5%NaHCO3 added per litre. Arterial pH wasestimated every two hours till it rose above7.384, when the addition of NaHCO3 was discontinued. Only 40% of the controlsattained normal pH in 12 hours, whereas allthe NaHCO3 group did, in an average of6.26 hours. Clinical improvement was rapid,and there were no adverse effects. Patientsretained an average of 43 mEq of Na during

the addition of NaHCO3. Units with artifi-cial kidneys could use HD for severely aci-dotic patients, but units lacking HD havefound this a useful addition to their arma-mentarium.

We have also been able to economise ondialysate in HD by using a slower f low. Arate of 350 ml per hour has been adequate inthe short term, and yielded a saving of 12%in the cost of each dialysis. We economise inCVVHD by using high f lux polysulfonedialysers instead of CVVH cartridges, whichcost four times as much. We established thata dialysate f low rate of one litre per hourcoupled with an ultraf iltration rate of onelitre per hour cost 26% less than a f low of one litre with ultraf iltration of 300 ml per hour, and 23% less than a f low of twolitres per hour with ultrafiltration of 500 mlper hour, to achieve equal clearances of ureaand creatinine.

Patients and their families spend morethan they can afford in an effort to save life.Every little we can save for them is valuable.

1. MANI MK, RAIBAGI MH, DIN-GANKAR AD: The economics of peri-toneal dialysis. A cost eff iciency study.Nephron 17: 130 - 134, 1976.

2. SRIKANTHAN R, PRABHAKARANJ, RAMKUMAR TS, SHIVANANDNAYAK K, SUBBA RAO B, RAMA-LINGAM KS, MANI MK: Cost effec-tiveness of a low dialysate f low rate inhemodialysis: a short term comparativestudy. Dialysis and Transplantation 19:125-126, 1990.

3. WIG N, MAHAJAN SK: Comparison ofsodium nitroprusside added peritonealdialysis and haemodialysis. Ind J Nephrol6: 81 - 85, 1996.

Dialysis for ARF in Developing Countries: Theory and Practice

continued from page 1

Paul Chrisp, PhD, MRPharmS

Editor-in-chief, Core Evidence

Improving outcomes of patients with

chronic renal failure is a primary aim of the

RRI and the readers of this newsletter.

Information on key clinical and economic

outcomes is critical, and healthcare providers

place increasing reliance on evidence-based

measures to evaluate new and existing inter-

ventions, and to help prioritize resources. A

problem exists however, as the evidence is

often scattered and not available in a form

that is useful.

A new peer-reviewed journal, Core

Evidence, was launched in July 2005 to

address this need. The aim of the journal is

to apply the principles of evidence-based

medicine to review the potential place of

drugs in therapy by focusing on clinically

relevant outcomes, particularly those that

matter to patients. The journal is published

by Core Medical Publishing Ltd, a new

independent publishing company with offices

in New York and Manchester, UK.

The evidence on new drugs from clinical

development and practice is systematically

evaluated in Core Evidence on the basis of

its relevance, validity, and credibility. Expert

opinion obtained during peer review adds

clinical context to each article. Published

four times a year, each issue of the journal

contains up to seven reviews, covering drugs

from phase I clinical trials through post-

launch. Drugs are selected on the basis of

their potential impact on patient outcomes,

disease management, and healthcare priori-

ties, and regularly reviewed throughout their

development.

These selection criteria mean that Core

Evidence covers a range of drugs and ther-

apy areas of relevance to nephrologists. In

the first issue of the journal, the evidence on

the use of sevelamer (Renagel®) as a phos-

phate binder is reviewed. As perhaps would

be expected, the review found clear evi-

dence for sevelamer's effectiveness as a phos-

phate binder. But it also supported the view

that sevelamer reduced vascular calcification

compared with calcium salts, with evidence

of reduced risk of cardiovascular morbidity

and mortality. There is also some evidence

that this reduction somewhat offsets the

higher cost of sevelamer compared with cal-

cium salts, although this needs to be con-

firmed by more direct evidence.

Readers of Dialysis Times may also be

interested to know that the novel antihyper-

tensive aliskiren is also reviewed in issue 1 of

Core Evidence. The drug, which is the first

renin inhibitor, is currently in phase III as

monotherapy and phase II as combination

therapy in patients with mild-to-moderate

hypertension, and in patients with diabetic

nephropathy. The emerging evidence indi-

cates equivalent eff icacy to angiotensin

receptor blockers.

Further information about Core Evidence

can be found on the Core Medical

Publishing website (http://www.coremed-

icalpublishing.com), or by contacting the

Editors at editor@coreevidence.com, or

914-220-8351.

New Evidence-Based Medicine Journal

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DIALYSIS TIMES Page 3

DIALYSIS TIMESpublished by

Renal Research Institute, LLC207 East 94th Street, Suite 303

New York, NY 10128Telephone 212-360-4900 • Fax 646-672-4174

E D I T O R I A L C O M M I T T E ENathan Levin, MD

J. Michael Lazarus, MDPeter Kotanko, MD

Mary Carter, MBA, MPHTom Graham

Danielle Callegari

The statements and opinions contained in the articles published in DialysisTimes are based upon the views of the author and do not necessarily ref lectthe opinions of the Renal Research Institute or any affiliated company oracademic institution. Renal Research Institute does not warrant, eitherexpressly or by implication, the factual accuracy of the articles herein, nordoes it warrant any views or opinions offered by the author of such articles.If you have any questions regarding information in this article, please con-tact the author directly. Any views, comments, or responses to this articleare welcome at dialysistimes@rriny.com.

To search past issues online, register to receive future issues, or submit articles or letters for publication, visit

www.renalresearch.com or e-mail dialysistimes@rriny.com.

New York - The care of kidney trans-

plant recipients will be the focus of a global

“Controversies Conference” organized

by “Kidney Disease: Improving Global

Outcomes” (KDIGO), a global organization

managed by the National Kidney

Foundation (NKF). The Conference will be

held February 2 - 4 in Lisbon, Portugal. Its

goal is to improve the outcomes of kidney

transplants worldwide. The Conference will

make general recommendations and define

key questions that require a rigorous scien-

tific process by which KDIGO will develop

evidence-based clinical practice guidelines

on the subject.

The Conference and KDIGO are man-

aged by the NKF, headquartered in New

York City. KDIGO is a three year old

organization created to launch a global effort

to improve outcomes through guidelines and

their implementation.

“Thousands of kidney transplantations

are performed each year, but their outcomes

and the shortage of organs remain a major

problem,” said Fred L. Brown, NKF

Chairman. “We urgently need to help recip-

ients live long and healthy lives with their

transplanted kidneys. We can improve

outcomes and reduce the need for second

transplants through development and imple-

mentation of guidelines on better care.”

“The NKF Board of Directors felt so

strongly about this vital issue that they are

donating the money themselves to make the

development of the guidelines possible,”

Brown added. “We are also fortunate to

have support from Wyeth Pharmaceuticals,

Amgen, the Dole Food Company,

Transwestern Commercial Services and the

Robert and Jane Cizik Foundation so that a

complete program of a Controversies

Conference, Guideline Development and

implementation programs can be organized.”

The Conference and subsequent guide-

line will focus on improving the clinical

management of transplant recipients. This

includes post-transplant complications such

as malignancy, diabetes, anemia, bone disease

and cardiovascular risks. These complications

threaten the recipient's life, the survival of

the graft, and increase the cost of care.

KDIGO's guideline process is modeled on

NKF's successful series of guidelines on

chronic kidney disease and its treatment

known as KDOQI or Kidney Disease

Outcomes Quality Initiative.

Co-chair of KDIGO, Dr. Garabed

Eknoyan of Houston, Texas said, “We can

do much better in caring for our trans-

planted patients. This Conference will bring

together nearly 100 experts from around the

world to deliberate and determine what we

know, what we can do with what we know

and what we still need to discover.”

Dr. Norbert Lamiere, KDIGO Co-chair,

announced that the Conference Co-chairs

will be Dr. Francis Delmonico of Harvard

Medical School and Dr. Martin Zeier of the

University of Heidelberg. The Conference

Steering Committee met recently in Boston

to plan the organization and content of the

Conference.

Guideline Development

Following the Conference, KDIGO will

begin an 18 month process to empower an

independent work group and three method-

ology centers from different parts of the

world to examine the evidence and create

practice guidelines recommending ways to

improve outcomes. Such recommendations

will focus on what practicing kidney doc-

tors, primary care doctors and patients

themselves can do to prevent the loss of an

organ or threats to the life of a recipient.

Outcomes can be improved through better

management of cardiovascular risk, other

complications and the relationship between

kidney disease and the suppression of a

patient's immune system.

A previous KDIGO Controversies

Conference established the principal that

transplant recipients whose kidney function

is compromised still have chronic kidney dis-

ease and must be treated aggressively.

“KDIGO would like to acknowledge

and express appreciation to the

Transplantation Society and the Global

Alliance for Transplantation for their partici-

pation and input in this collaborative effort

toward our shared objective of improving

outcomes for kidney transplant recipients

throughout the world,” said John Davis,

CEO of the National Kidney Foundation.

KDIGO is a Belgian not-for-profit

foundation with a 40 member international

Board of Directors and managed by NKF. Its

mission is to improve outcomes for kidney

patients worldwide through coordination,

development and implementation of practice

guidelines.

Global Transplant Conference to Lay Groundwork for New Clinical Practice Guideline

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By Jennifer Cheng MS, RDThe holiday season with its culinary

temptations can challenge even the mostcompliant dialysis patients. During the fes-tivities, indulging in food and drinks inexcess can be difficult to avoid. In this time,many will gain a few “holiday pounds” andlose their resolve to stay on their diets.Unfortunately, this deviation can have harm-ful effects on our dialysis patients.

Our patients might enjoy a few mealseither eating out in restaurants or gatheringwith family and friends in their homes. Inboth situations, patients will definitely comeacross tempting holiday treats. These holidayfoods are often rich sources of phosphorus,potassium, and sodium. As our patientsattend parties and join family gatherings,they may also need to closely monitor theirf luid intake and, for diabetics, consumptionof concentrated sweets. The following aresome tips on how to stay in control of thesechallenges.

Phosphorus: Eggnog, macaroni &cheese, ice cream and chocolate are justsome of the high phosphorus foods foundaround the holidays. Patients need to bereminded that they must take their phos-phate binders with EVERY meal and snack.Dosage of these binders should also bereviewed; patients should learn to adjust thenumber of binders they take with the size ofthe meal they consume or with the presenceof high phosphorus foods.

Ideally the patients would adjust thenumber of phosphate binders to the phos-phorus content of each meal (e.g 1 binderper each 100 mg of phosphorus). An innova-tive education program has recently beendeveloped in Germany which allows toteach patients to accurately estimate the mealphosphorus content by eye. According tothis new concept the meal phosphorus con-tent is estimated by phosphate units, not bemilligrams, and phosphate binders are dosedin relation to the total number of phosphateunits contained in a meal (e.g. 1 binder perphosphate unit). First practical experienceswith the phosphate education program(PEP®) indicate high physician, dieticianand patient satisfaction and a high compli-ance rate. (for more information: m-k-kuhlmann@web.de)

Often when patients eat out, they tendto neglect to take their phosphate binders.

Eating out is a great way to enjoy differentcuisines, but noncompliance with theirbinders when eating out should not becomea habit. Advise patients to put their bindersin small pill boxes and set them out on thetable before they begin their meal so thatthey will be reminded to take their binders.

Potassium: Allowing patients to have asmall serving of their favorite high potassiumfood will let them satisfy their craving andhelp them feel less deprived during the holi-day season. Some popular high potassiumfoods are sweet potato, brussel sprouts,beans, squash and spinach. Of course, renalpatients should also continue to avoid toma-toes, potatoes, bananas and oranges.

In the case of potatoes and sweet pota-toes, patients can “dialyze” or leach outsome of the potassium out of these vegeta-bles by these 4 steps:1. Peel, cut and soak vegetable overnight in

a large bowl.2. Next day, throw away the water.3. Cook vegetable in fresh water. 4. Incorporate into recipe as desired.

It is important to remember that leach-ing does not reduce phosphorus content andwill not remove all of the potassium; there-fore, portion control is still important to pre-vent hyperkalemia.

Sodium: Sodium content of foods can behighly variable depending on the amount ofsalt added during cooking, but some foodsare salty even before cooking. For example,these foods include canned foods, processedmeats/fishes, and frozen foods. When eatingout, patients should also be cautious ofsauces and dips as these foods often haveadditional salt added to them during thecooking process. “Dining Out for theDialysis Patients” (below) further explainsthe pitfalls in food choices of each cuisine.

Fluids: If a patient chooses to have alco-hol, advise them to avoid high potassiumcocktails such as Bloody Marys, Screwdrivers,and Pina Coladas. Eggnog and hot chocolateare high in phosphorus. Remind yourpatients that these beverages should becounted as part of their daily f luidallowance.

Concentrated Sweets: These foodsinclude cake, ice cream, cookies, and pie.Our patients may want to indulge and treatthemselves to various desserts that are notregularly included in their diet. The effect of

this is more important for those with dia-betes. These patients should be encouragedto monitor their blood sugar daily and tolimit their portion sizes of concentratedsweets.

During this time, our patients need extraencouragement and advice with adhering totheir renal diet. With a little planning ahead,our patients can learn to choose appropriatefoods from a restaurant menu and modifytheir traditional holiday recipes into “RenalFriendly” foods that everyone can enjoy!

Dining Out for the Dialysis Patient

Restaurants foods are often higher insodium than those prepared at home.Remind your patients to control theirsodium and f luid intake for the rest of theday as they may have increased thirst after arestaurant meal.

The trick with eating out at restaurants isto watch the portion sizes. Eating a largeamount of low phosphorus or low potassiumfoods can result in a high phosphorus and/orpotassium load in the body. To manage this,tell your patients to ask for a take-out boxand transfer half of their meal into the boxand save it for another day.

Italian Food: Ask for “sauce on the side.”Most Italian dishes either contain tomato-based red sauces (which are high in potas-sium) or cream-based white sauces (whichare high in phosphorus). A good choicewould be pesto or garlic and oil sauces.Pizzas are high in sodium, potassium andphosphorus from the tomato sauce andcheese.

Asian Food: Avoid dishes that are sautéedwith soy, hoisin, and sweet and sour sauces.These sauces tend to be high in sodium andmonosodium glutamate (MSG). Betterchoices would be stir-fry vegetables withfresh garlic, steamed fish (without the soysauce), and grilled fish or chicken.

Mexican Food: Mexican food contains alot of beans, tomatoes, and cheese that arehigh in potassium, phosphorus and sodium.Avocados are also high in potassium. A goodchoice would be meat tacos with plain rice.

Jennifer Cheng MS, RD is a Renal Dietitianat Upper Manhattan Dialysis Center. She has aMasters degree in Nutrition Education fromColumbia University. Ms. Cheng contributes tothe monthly “UMDC HealthLink” newsletterwith renal diet advice for UMDC patients.

Renal-Friendly Holiday Eating

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CKD On Capitol Hill

By Mohammed AliToday about 20 million Americans - 1 in 9 US

adults - have CKD and millions more are at risk.

Groups which are at increased risk for kidney disease

include African Americans, Hispanics, Pacif ic

Islanders, Native Americans and seniors.1

Since 1991, costs for the Medicare and ESRD

programs have grown 110 and 196 percent. The

ESRD program now accounts for 6.7 percent of the

Medicare budget, up 41 percent over the last 11

years. In 2002, ESRD spending reached $16.2 billion

for Medicare paid claims, $3.6 billion for Medicare

patient obligations, $0.83 billion for Medicare HMO

costs, and $4.7 billion for non-Medicare costs;

Compared to the Medicare program, and even after

taking deductibles and co-pays into account,

employer group health plans pay close to a $50,000

premium for treating younger ESRD patients.2

While the cost of dialysis treatment and its med-

ications is high, its benefits are only increased with

treatment increasing the three times a week threshold,

frequent HD makes a formidable case for frequent

therapies. Data showed that regimens associated with

the best biochemical profiles; volume, hypertension

control, and nutritional status do not provide the evi-

dence for superior survival when compared to long

nocturnal thrice-weekly or every-other-day conven-

tional HD. This correlation between frequency and

clinical outcomes may seem very clear, but may not

be directly linear. Perhaps the greatest benefits are

gained from the simple avoidance of 48 hr without

dialysis. By avoiding this gap, the benefits of dialysis

may be increased to better patient life.3

Currently Renal Research Institute, LLC based

in New York and two other organizations are recipi-

ents of cooperative agreement grants from the

National Institute of Diabetes and Digestive and

Kidney Diseases (NIDDK) to conduct clinical trials

on daily or more frequent hemodialysis. The benefit

of more frequent treatments is something that cannot

be denied, to prove these benefits will prove to be

invaluable. The NIDDK is interested in understand-

ing the potential medical benefits of more frequent

dialysis for patients with end stage kidney disease.

These recent awards from the NIDDK, as part of the

National Institutes of Health (NIH) and U.S.

Department of Health & Human Services, will exam-

ine the feasibility of randomization of patients to a

more frequent than current dialysis schedule with the

eventual aim of constituting a trial with suff icient

power to study differences in patient outcomes. This

is a 4 year project which is currently underway and

shows promise of great results.4

Recently the issues of dialysis and its costs as well

as the necessity of quality dialysis care have been

brought to the government's attention coinciding

with the steady increase in the dialysis population

which is predicted to grow over the next few years.5

Two new bills have been introduced to Congress.

The first one entitled Kidney Patient More Frequent

Dialysis Quality Act of 2005 H.R. 3096, was submit-

ted to the House of Representatives. The bill is to

amend title XVIII of the Social Security Act to pro-

vide for payment under the Medicare Program for

more frequent hemodialysis treatments. The bill pro-

poses to cover the treatment cost of dialysis treatment

if it is given four to five times a week compared to

the conventional thrice weekly as it is currently

scheduled for most dialysis patients nationwide. If

approved the bill will be a help in bringing the ideal-

ization of more frequent hemodialysis with the elimi-

nation of a 48 hour gap in dialysis sessions to life; a

move which is hypothesized to better the quality of

life for a dialysis patient.6

The second bill is in the senate entitled Kidney

Care Quality Act of 2005, S.635. The bill is endorsed

by U.S. Senator Rick Santorum (R-PA), Chairman

of the Senate Republican Conference Senator Kent

Conrad (D-ND) and members of the Washington

Redskins professional football team. They have all

teamed up to raise awareness for the bill. The act

seeks to improve the quality of care for End Stage

Renal Disease (ESRD) patients as well as the financial

stability of Medicare's ESRD program.7

Currently, Medicare reimburses dialysis facilities

through a prospective payment system (PPS) known

as the “composite rate,” which pays these providers

each time they administer dialysis to a patient.

However, unlike every other Medicare PPS, the

composite rate has no automatic annual payment

update mechanism to keep dialysis reimbursement in

line with the rising costs of providing care. The lack

of a payment update mechanism for dialysis providers

poses unique issues in terms of patient access to this

vital healthcare service.

The bills have support from various organiza-

tions, including the National Kidney Foundation

(NKF). “The Kidney Care Quality Act would make

it possible for providers to continue to improve the

quality of care and the other provisions in the legisla-

tion will address the goals of the foundation to reach

out to patients in earlier stages to improve their out-

comes as well” said Dolph Chianchiano Vice

President for Health Policy at the NKF. When asked

to comment on the Frequent Hemodialysis act Mr.

Chianchiano stated “more frequent dialysis is appro-

priate for certain patients and this legislation will

make it more accessible to the care they need”.

Dialysis is a life saving treatment method and for

now the only ray of light for people who have kidney

failure, at least until someone donates a kidney.

1 National Kidney Foundation

2 United States Renal Data Services

3 Hemodial Int. 2005 Jul; 9(3):309-13. “Beyond thrice-

weekly hemodialysis” Diaz-Buxo JA.

4 Fresenius Medical Care AG

5 Blood Purification 2004;22:6-8 “The Drumbeat of

Renal Failure: Symbiosis of Prevention and Renal

Replacement Therapy” , John H. Dirks;

6 Local Government website;

http://thomas.loc.gov/cgi-bin/query/z?c109:H.R.3096:

7 Office of Senator Rick Santorum

Paul Zabetakis, M.D., Chief Executive Officer of

Fresenius Medical Care Extracorporeal Alliance will

assume the additional responsibility of President,

Renal Research Institute (RRI), responsible for

Administration and Operations of managing RRI

clinics.

Nathan Levin, M.D., will continue as Medical

and Research Director of RRI and Chief Scientific

Officer for Fresenius Medical Care. He will continue

to have responsibility for the ongoing research activi-

ties of RRI.

The role of Research Laboratory Director will be

held by Peter Kotanko, M.D., from Hospital

Barmherzige Bruder, Teaching Hospital Medical

University of Graz, Austria. Dr. Kotanko will con-

tinue to oversee and manage all research laboratory

studies and activities. RRI is recognized for its signif-

icant research contributions to the renal field.

Renal Research Institute Update

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