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  • 1
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    Diagnostic Accuracy of Serum Parathyroid Hormone Levels in Kidney Transplant Recipients with Moderate-to-Advanced CKD
    S. Karger AG ; 2010
    In:  Nephron Clinical Practice Vol. 118, No. 2 ( 2010-12-8), p. c78-c85
    Details
    In: Nephron Clinical Practice, S. Karger AG, Vol. 118, No. 2 ( 2010-12-8), p. c78-c85
    Abstract: 〈 i 〉 Background/Aims: 〈 /i 〉 Elevated parathyroid hormone (PTH) is used to diagnose high turnover bone disease in chronic kidney disease (CKD). The diagnostic accuracy of PTH in kidney transplant recipients with CKD is unknown. 〈 i 〉 Methods: 〈 /i 〉 We examined kidney transplant recipients with CKD stages 3 (n = 498) and 4 (n = 141) to determine the sensitivity and specificity of the Kidney/Dialysis Outcome Quality Initiative (K/DOQI)-recommended PTH levels in detecting elevated serum β-CrossLaps (CTX) or osteocalcin (OC) levels. We performed receiver-operator curve analyses to determine CKD stage-specific PTH levels that provide optimal diagnostic accuracy. 〈 i 〉 Results: 〈 /i 〉 PTH below the lower limits of the K/DOQI ranges (35 and 70 pg/ml in CKD stages 3 and 4, respectively) showed sensitivity of 〉 90% in diagnosing increases in biochemical markers. The upper limits (70 and 110 pg/ml), however, showed poor specificity. A specificity of 〉 90% for detecting increased biochemical markers was seen with PTH of 〉 140 and 〉 240 pg/ml in CKD stages 3 and 4, respectively. 〈 i 〉 Conclusion: 〈 /i 〉 Currently applied cutoffs for PTH in kidney transplant recipients with CKD stages 3 and 4 do not appear to adequately detect increased biochemical markers of bone turnover. Diagnostic uncertainty exists in patients with CKD stage 3 and PTH between 35 and 140 pg/ml, and CKD stage 4 and PTH between 70 and 240 pg/ml.
    Type of Medium: Online Resource
    ISSN: 1660-2110
    URL: Article
    DOI: 10.1159/000320318
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2010
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  • 2
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    The Role of Fibroblast Growth Factor-23 in Cardiorenal Syndrome
    S. Karger AG ; 2013
    In:  Nephron Clinical Practice Vol. 123, No. 3-4 ( 2013-8-6), p. 194-201
    Details
    In: Nephron Clinical Practice, S. Karger AG, Vol. 123, No. 3-4 ( 2013-8-6), p. 194-201
    Abstract: Abnormalities in chronic kidney disease-related bone and mineral metabolism (CKD-MBD) have emerged as novel risk factors in excess cardiovascular mortality in patients with CKD and end-stage renal disease (ESRD). The pathophysiological links between CKD-MBD and adverse cardiovascular events in this patient population are unclear. Hyperphosphatemia through induction of vascular calcifications and decreased active vitamin D production leading to activation of the renin angiotensin system (RAS) along with defects in innate immunity are purported to be the proximate cause of CKD-MBD-associated mortality in CKD. Recently, this view has been challenged by the observation that fibroblast growth factor-23 (FGF23), a newly discovered hormone produced in the bone that regulates phosphate and vitamin D metabolism by the kidney, is a strong predictor of adverse cardiovascular outcomes in patients with CKD and ESRD. Whether these associations between elevated circulating FGF23 levels and cardiovascular outcomes are causative, and if so, the mechanisms mediating the effects of FGF23 on the cardiovascular system are not clear. The principal physiological functions of FGF23 are mediated by activation of FGF receptor/α-klotho coreceptor complexes in target tissues. Elevated FGF23 has been associated with left ventricular hypertrophy (LVH), and it has been suggested that FGF23 may induce myocardial hypertrophy through a direct effect on cardiac myocytes. A direct ‘off target' effect of FGF23 on LVH is controversial, however, since α-klotho (which is believed to be indispensable for the physiologic actions of FGF23) is not expressed in the myocardium. Another possibility is that FGF23's effect on the heart is mediated indirectly, via ‘on target' regulation of hormonal pathways in the kidney, which include suppression of angiotensin-converting enzyme 2, Cyp27b1and α-klotho, which would be predicted to act on circulating factors known to regulate RAS, 1,25(OH) 〈 sub 〉 2 〈 /sub 〉 D production and ion transport in the myocardium. Understanding of FGF23's pathophysiology and mechanisms of action responsible for its negative effects will be necessary to develop therapeutic strategies to treat CKD-MBD.
    Type of Medium: Online Resource
    ISSN: 1660-2110
    URL: Article
    DOI: 10.1159/000353593
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2013
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  • 3
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    Association of Hypo- and Hyperkalemia with Disease Progression and Mortality in Males with Chronic Kidney Disease: The Role of Race
    S. Karger AG ; 2011
    In:  Nephron Clinical Practice Vol. 120, No. 1 ( 2011-12-2)
    Details
    In: Nephron Clinical Practice, S. Karger AG, Vol. 120, No. 1 ( 2011-12-2)
    Abstract: 〈 b 〉 〈 i 〉 Background/Aims: 〈 /i 〉 〈 /b 〉 Abnormal serum potassium is associated with higher mortality in dialysis patients, but its impact on outcomes in predialysis chronic kidney disease (CKD) is less clear. Furthermore, blacks with normal kidney function have lower urinary potassium excretion, but it is unclear if such differences have a bearing on race-associated outcomes in CKD. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 We studied predialysis mortality and slopes of estimated glomerular filtration rate, eGFR) associated with serum potassium in 1,227 males with CKD. Mortality was examined in time-dependent Cox models, and slopes of eGFR in linear mixed effects models with adjustments for case mix and laboratory values. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 Both hypo- and hyperkalemia were associated with mortality overall and in 933 white patients, but in 294 blacks hypokalemia was a stronger death predictor. Hypokalemia was associated with loss of kidney function independent of race: a 1 mEq/l lower potassium was associated with an adjusted difference in slopes of eGFR of -0.13 ml/min/1.73 m 〈 sup 〉 2 〈 /sup 〉 /year (95% CI: -0.20 to -0.07), p 〈 0.001. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 Hypo- and hyperkalemia are associated with higher mortality in CKD patients. Blacks appear to better tolerate higher potassium than whites. Hypokalemia is associated with faster CKD progression independent of race. Hyperkalemia management may warrant race-specific consideration, and hypokalemia correction may slow CKD progression. This is a work of the US Government and is not subject to copyright protection in the USA. Foreign copyrights may apply. Published by S. Karger AG, Basel
    Type of Medium: Online Resource
    ISSN: 1660-2110
    URL: Article
    DOI: 10.1159/000329511
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2011
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  • 4
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    Triglycerides and Renal Outcomes According to Albuminuria and in Consideration of Other Metabolic Syndrome Components in Diabetic US Veterans
    S. Karger AG ; 2023
    In:  American Journal of Nephrology Vol. 54, No. 1-2 ( 2023), p. 14-24
    Details
    In: American Journal of Nephrology, S. Karger AG, Vol. 54, No. 1-2 ( 2023), p. 14-24
    Abstract: 〈 b 〉 〈 i 〉 Introduction: 〈 /i 〉 〈 /b 〉 Hypertriglyceridemia, a component of the metabolic syndrome, is a known independent predictor of albuminuria and chronic kidney disease (CKD) in the general population. Previous studies have shown that the relationship of triglycerides (TGs) with outcomes changes across stages of CKD. Our objective was to examine the association of TG independent of other metabolic syndrome components with renal outcomes in diabetic patients with or without CKD. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 This retrospective cohort study included diabetic US veteran patients with valid data on TGs, estimated glomerular filtration rate (eGFR), and albuminuria (urinary albumin/creatinine ratio) between fiscal years 2004 and 2006. Using Cox models adjusted for clinical characteristics and laboratory markers, we evaluated the relationship of TG with incident albuminuria (stratified by eGFR category) and based on eGFR (stratified by baseline albuminuria categories). To evaluate the relationship of TG with time to end-stage renal disease (ESRD), we stratified models by baseline CKD stage (eGFR category) and baseline albuminuria stage ascertained at time of TG measurement. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 In a cohort of 138,675 diabetic veterans, the mean ± SD age was 65 ± 11 years old and included 3% females and 14% African Americans. The cohort also included 28% of patients with non-dialysis-dependent CKD (eGFR & lt;60 mL/min/1.73 m 〈 sup 〉 2 〈 /sup 〉 ), as well as 28% of patients with albuminuria (≥30 mg/g). The median (IQR) of serum TG was 148 (100, 222) mg/dL. We observed a slight positive linear association between TG and incident CKD after adjustment for Case-Mix and Laboratory variables among non-albuminuric and microalbuminuric patients. The relationship of high TG trended towards a higher risk of ESRD in CKD 3A non-albuminuric patients and in CKD 3A and 4/5 patients with microalbuminuria. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 In a large cohort, we have shown that elevated TGs are associated with all kidney outcomes tested independently of other metabolic syndrome components in diabetic patients with normal eGFR and normal albumin excretion rate, but the association is weaker in some groups of diabetic patients with preexisting renal complications.
    Type of Medium: Online Resource
    ISSN: 0250-8095 , 1421-9670
    URL: Article
    DOI: 10.1159/000529414
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2023
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  • 5
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    Racial and Ethnic Differences in Mortality of Hemodialysis Patients: Role of Dietary and Nutritional Status and Inflammation
    S. Karger AG ; 2011
    In:  American Journal of Nephrology Vol. 33, No. 2 ( 2011), p. 157-167
    Details
    In: American Journal of Nephrology, S. Karger AG, Vol. 33, No. 2 ( 2011), p. 157-167
    Abstract: 〈 i 〉 Background: 〈 /i 〉 Racial/ethnic disparities prevail among hemodialysis patients. We hypothesized that significant differences exist between Black and non-Hispanic and Hispanic White hemodialysis patients in nutritional status, dietary intake and inflammation, and that they account for racial survival disparities. 〈 i 〉 Methods: 〈 /i 〉 In a 6-year (2001–2007) cohort of 799 hemodialysis patients, we compared diet and surrogates of nutritional-inflammatory status and their mortality-predictabilities between 279 Blacks and 520 Whites using matched and regression analyses and Cox with cubic splines. 〈 i 〉 Results: 〈 /i 〉 In age-, gender- and diabetes-matched analyses, Blacks had higher lean body mass and serum prealbumin, creatinine and homocysteine levels than Whites. In case-mix-adjusted analyses, dietary intakes in Blacks versus Whites were higher in energy (+293 ± 119 cal/day) and fat (+18 ± 5 g/day), but lower in fiber (–2.9 ± 1.3 g/day) than Whites. In both races, higher serum albumin, prealbumin and creatinine were associated with greater survival, whereas CRP and IL-6, but not TNF-α, were associated with increased mortality. The highest (vs. lowest) quartile of IL-6 was associated with a 2.4-fold (95% CI: 1.3–3.8) and 4.1-fold (2.2–7.2) higher death risk in Blacks and Whites, respectively. 〈 i 〉 Conclusions: 〈 /i 〉 Significant racial disparities exist in dietary, nutritional and inflammatory measures, which may contribute to hemodialysis outcome disparities. Testing race-specific dietary and/or anti-inflammatory interventions is indicated.
    Type of Medium: Online Resource
    ISSN: 0250-8095 , 1421-9670
    URL: Article
    DOI: 10.1159/000323972
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2011
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  • 6
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    Association of Pre-ESRD Serum Bicarbonate with Post-ESRD Mortality in Patients with Incident ESRD
    S. Karger AG ; 2021
    In:  American Journal of Nephrology Vol. 52, No. 4 ( 2021), p. 304-317
    Details
    In: American Journal of Nephrology, S. Karger AG, Vol. 52, No. 4 ( 2021), p. 304-317
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Serum bicarbonate or total carbon dioxide (CO 〈 sub 〉 2 〈 /sub 〉 ) concentrations decline as chronic kidney disease (CKD) progresses and rise after dialysis initiation. While metabolic acidosis accelerates the progression of CKD and is associated with higher mortality among patients with end stage renal disease (ESRD), there are scarce data on the association of CO 〈 sub 〉 2 〈 /sub 〉 concentrations before ESRD transition with post-ESRD mortality. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 A historical cohort from the Transition of Care in CKD (TC-CKD) study includes 85,505 veterans who transitioned to ESRD from October 1, 2007, through March 31, 2014. After 1,958 patients without follow-up data, 3 patients with missing date of birth, and 50,889 patients without CO 〈 sub 〉 2 〈 /sub 〉 6 months prior to ESRD transition were excluded, the study population includes 32,655 patients. Associations between CO 〈 sub 〉 2 〈 /sub 〉 concentrations averaged over the last 6 months and its rate of decline during the 12 months prior to ESRD transition and post-ESRD all-cause, cardiovascular (CV), and non-CV mortality were examined by using hierarchical adjustment with Cox regression models. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 The cohort was on average 68 ± 11 years old and included 29% Black veterans. Baseline concentrations of CO 〈 sub 〉 2 〈 /sub 〉 were 23 ± 4 mEq/L, and median (interquartile range) change in CO 〈 sub 〉 2 〈 /sub 〉 were −1.8 [−3.4, −0.2] mEq/L/year. High (≥28 mEq/L) and low ( & #x3c;18 mEq/L) CO 〈 sub 〉 2 〈 /sub 〉 concentrations showed higher adjusted mortality risk while there was no clear trend in the middle range. Consistent associations were observed irrespective of sodium bicarbonate use. There was also a U-shaped association between the change in CO 〈 sub 〉 2 〈 /sub 〉 and all-cause, CV, and non-CV mortality with the lowest risk approximately at −2.0 and 0.0 mEq/L/year among sodium bicarbonate nonusers and users, respectively, and the highest mortality was among patients with decline in CO 〈 sub 〉 2 〈 /sub 〉 & #x3e;4 mEq/L/year. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 Both high and low pre-ESRD CO 〈 sub 〉 2 〈 /sub 〉 levels (≥28 and & #x3c;18 mEq/L) during 6 months prior to dialysis transition and rate of CO 〈 sub 〉 2 〈 /sub 〉 decline & #x3e;4 mEq/L/year during 1 year before dialysis initiation were associated with greater post-ESRD all-cause, CV, and non-CV mortality. Further studies are needed to determine the optimal management of CO 〈 sub 〉 2 〈 /sub 〉 in patients with advanced CKD stages transitioning to ESRD.
    Type of Medium: Online Resource
    ISSN: 0250-8095 , 1421-9670
    URL: Article
    DOI: 10.1159/000513855
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2021
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  • 7
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    Ultrafiltration Rate Effects Declines in Residual Kidney Function in Hemodialysis Patients
    S. Karger AG ; 2019
    In:  American Journal of Nephrology Vol. 50, No. 6 ( 2019), p. 481-488
    Details
    In: American Journal of Nephrology, S. Karger AG, Vol. 50, No. 6 ( 2019), p. 481-488
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 High ultrafiltration rate (UFR) has been associated with increased mortality in hemodialysis (HD) patients. However, the impact of UFR on decline of residual kidney function (RKF) has not been elucidated among patients receiving conventional HD. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 We performed a retrospective cohort study of 7,753 patients who initiated conventional HD from 2007 to 2011 and survived the first year of dialysis with baseline UFR and renal urea clearance (KRU) data at baseline and 1 year (5th patient-quarter). The primary exposure was average UFR at the 1st patient-quarter from dialysis initiation ( & #x3c;4, 4 to & #x3c;6, 6 to & #x3c;9, 9 to & #x3c;13, and ≥13 mL/h/kg). Decline in RKF was defined as the percent change in KRU and decline in urine output during the first year after initiation of dialysis. We used a logistic regression model for rapid decline in RKF and a linear regression model for change in urine volume. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 In our HD cohort, mean baseline UFR was 7.0 ± 3.1 mL/h/kg, and median (interquartile range) baseline KRU was 3.5 (2.1–5.3) mL/min/1.73 m 〈 sup 〉 2 〈 /sup 〉 . There was a graded association between UFR and a rapid decline in RKF; the expanded case mix-adjusted ORs and 95% CIs were 1.21 (1.04–1.40), 1.34 (1.16–1.55), 1.73 (1.46–2.04), and 1.93 (1.48–2.52) for baseline UFR 4 to & #x3c;6, 6 to & #x3c;9, 9 to & #x3c;13, and ≥13  mL/h/kg, respectively (reference: & #x3c;4 mL/h/kg). KRU trajectories showed a greater KRU decline over time in higher UFR categories. Higher UFR was also associated with a greater decline in urine output after 1 year. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 Higher UFR was associated with a rapid decline in RKF among conventional HD patients. Further clinical trials are needed to elucidate a causal effect of UFR on RKF among HD patients.
    Type of Medium: Online Resource
    ISSN: 0250-8095 , 1421-9670
    URL: Article
    DOI: 10.1159/000503918
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2019
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  • 8
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    Obesity and Kidney Disease: Hidden Consequences of the Epidemic
    S. Karger AG ; 2017
    In:  Nephron Vol. 135, No. 4 ( 2017), p. 243-251
    Details
    In: Nephron, S. Karger AG, Vol. 135, No. 4 ( 2017), p. 243-251
    Abstract: Obesity has become a worldwide epidemic, and its prevalence has been projected to grow by 40% in the next decade. This increasing prevalence has implications for the risk of diabetes, cardiovascular disease, and also for chronic kidney disease. A high body mass index is one of the strongest risk factors for new-onset chronic kidney disease. In individuals affected by obesity, a compensatory hyperfiltration occurs to meet the heightened metabolic demands of the increased body weight. The increase in intraglomerular pressure can damage the kidneys and raise the risk of developing chronic kidney disease in the long-term. The incidence of obesity-related glomerulopathy has increased 10-fold in recent years. Obesity has also been shown to be a risk factor for nephrolithiasis, and for a number of malignancies including kidney cancer. This year, the World Kidney Day promotes education on the harmful consequences of obesity and its association with kidney disease, advocating healthy lifestyle and health policy measures that make preventive behaviors an affordable option.
    Type of Medium: Online Resource
    ISSN: 1660-8151 , 2235-3186
    URL: Article
    DOI: 10.1159/000455698
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2017
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  • 9
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    Effect of Age on the Association of Vascular Access Type with Mortality in a Cohort of Incident End-Stage Renal Disease Patients
    S. Karger AG ; 2017
    In:  Nephron Vol. 137, No. 1 ( 2017), p. 57-63
    Details
    In: Nephron, S. Karger AG, Vol. 137, No. 1 ( 2017), p. 57-63
    Abstract: 〈 b 〉 〈 i 〉 Background/Aims: 〈 /i 〉 〈 /b 〉 All hemodialysis (HD) patients are generally recommended to create a fistula first; but to create a mature arteriovenous fistula (AVF) can be challenging in elderly individuals. It is unclear if elderly incident HD patients derive a survival benefit from an AVF over an arteriovenous graft (AVG) or a tunneled central venous catheter (TDC). 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 We examined the association of vascular access type (AVF, AVG, and TDC with and without a maturing AVF/AVG at dialysis transition) at HD initiation with all-cause, cardiovascular (CV), and infection-related mortality in 46,786 US veterans using Cox models with adjustment for confounders. Effect modification by age was examined by examining associations in pre-specified age subgroups ( 〈 60, 60- 〈 70, 70- 〈 80, and ≥80 years old), and by including interaction terms. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 Patients numbering 8,940 (19%) started HD with an AVF, 1,090 (3%) with an AVG, 8,262 (18%) with a TDC and a maturing AVF/AVG and 28,494 (61%) with a TDC without a maturing AVF/AVG. A total of 13,303 all-cause, 4,392 CV, and 1,058 infection-related deaths were observed in the first year after HD transition. Compared to patients with AVF, those with AVG and TDC with and without maturing AVF/AVG had incrementally higher overall risk of all-cause mortality and CV mortality. Only TDC use was associated with higher infection-associated mortality. These associations were not modified by age. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 Although most of our patients consisted of male veterans and the results may not be generalized to the general population, the use of TDCs is associated with poor outcomes even in the most elderly incident HD patients.
    Type of Medium: Online Resource
    ISSN: 1660-8151 , 2235-3186
    URL: Article
    DOI: 10.1159/000477271
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2017
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  • 10
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    Association of Ultrafiltration Rate with Mortality in Incident Hemodialysis Patients
    S. Karger AG ; 2018
    In:  Nephron Vol. 139, No. 1 ( 2018), p. 13-22
    Details
    In: Nephron, S. Karger AG, Vol. 139, No. 1 ( 2018), p. 13-22
    Abstract: 〈 b 〉 Background/Aims: 〈 /b 〉 Ultrafiltration rate (UFR) appears to be associated with mortality in prevalent hemodialysis (HD) patients. However, the association of UFR with mortality in incident HD patients remains unknown. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 We examined a US cohort of 110,880 patients who initiated HD from 2007 to 2011. Baseline UFR was divided into 5 groups ( & #x3c;4, 4 to & #x3c;6, 6 to & #x3c;8, 8 to & #x3c;10, and ≥10 mL/h/kg body weight [BW]). We examined predictors of higher baseline UFR using logistic regression and the association of baseline UFR and all-cause and cardiovascular (CV) mortality using Cox proportional hazard models with adjustments for demographics, comorbidities, and markers of malnutrition-inflammation-cachexia syndrome. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 Patients were 63 ± 15 years, with 43% women, 32% African Americans, and had a mean baseline UFR of 7.5 ± 3.1 mL/h/kg BW. In the fully adjusted logistic regression models, factors associated with higher UFR (≥7.5 mL/h/kg BW) included Hispanic ethnicity, diabetes, and higher dietary protein intake. There was a linear association between UFR and all-cause and CV mortality, where UFR ≥10 mL/h/kg BW (reference UFR 6– & #x3c;8 mL/h/kg BW) conferred the highest risk in both unadjusted (HR 1.15 [95% CI 1.10–1.19]) and adjusted models (HR 1.23 [95% CI 1.16–1.31] ). The linear association with all-cause mortality remained consistent across strata of age, urine volume, and treatment time. 〈 b 〉 〈 i 〉 Conclusions: 〈 /i 〉 〈 /b 〉 Higher UFR is independently associated with higher all-cause and CV mortality in incident HD patients. Clinical trials are warranted to examine the effects of lowering UFR on outcomes.
    Type of Medium: Online Resource
    ISSN: 1660-8151 , 2235-3186
    URL: Article
    DOI: 10.1159/000486323
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2018
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