Publications

Found 21 results

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2020
Sola L, Levin NW, Johnson DW, Pecoits-Filho R, Aljubori HM, Chen Y, Claus S, Collins A, Cullis B, Feehally J, Harden PN, Hassan MH, Ibhais F, Kalantar-Zadeh K, Levin A, Saleh A, Schneditz D, Tchokhonelidze I, Kazancioglu RT, Twahir A, Walker R, Were AJO, Yu X, Finkelstein FO. "Development of a framework for minimum and optimal safety and quality standards for hemodialysis and peritoneal dialysis." Kidney International Supplements. 2020.
Elsayed HM, Wadee S, Zaki MS, Were AJO, Ashuntantang GE, Bamgboye EL, Davids MR, Hafez MH, Mahamat M, Naicker S, Niang A, Seck SM, Swanepoel CR, Tannor EK, Twahir A, Yao HK. "Guidelines for the prevention, detection and management of the renal complications of COVID-19 in Africa." African Journal of Nephrology. 2020;23(1). AbstractWebsite

Africa trails the rest of the world in COVID-19 cases and deaths. However, as the pandemic spreads through the continent, we expect increases in community infection in the months ahead. Patients with kidney infection, especially those with end-stage kidney disease and those with kidney transplants, are at high risk for acquiring the disease and dying from it. While there is limited evidence for the benefit of interventions, we have the advantage of learning from the experiences of those in China, Europe and the Americas. This document sets forth guidance for dealing with our patients who have acute and chronic kidney disease, including those on renal replacement therapy and the staff involved in their care. Emphasis is placed on preparedness and prevention strategies. As evidence and experience accumulate, it is likely that updated guidance will be needed.

L’Afrique suit le reste du monde en termes de nombre de cas et de décès dus à COVID-19. Cependant, alors que la pandémie se propage à travers le continent, nous prévoyons une augmentation de l’infection communautaire dans les mois à venir. Les patients atteints d’une maladie rénale, en particulier ceux atteints d’une maladie rénale chronique en phase terminale et ceux ayant subi une transplantation rénale, courent un risque élevé de contracter la maladie et d’en mourir. Bien que les preuves d’interventions soient limitées, nous avons l’avantage de tirer des enseignements des expériences de ceux qui se trouvent en Chine, en Europe et dans les Amériques. Ce document présente des conseils pour traiter nos patients atteints d’insuffisance rénale aiguë et chronique, y compris ceux sous thérapie de suppléance rénale et le personnel impliqué dans leurs soins. L’accent est mis sur les stratégies de préparation et de prévention. Au fur et à mesure que les preuves et l’expérience s’accumulent, il est probable que des directives actualisées seront nécessaires.

J.O'Connell P, Brown M, Chan TM, Granado RC-D, J.Davies S, Eiam-Ong S, H.Hassan M, Kalantar-Zadeh K, Levin A, E.Martin D, Muller E, Ossareh S, Tchokhonelidze I, Trask M, Twahir A, J.O.Were A, Yang C-W, Zemchenkov A, N.Harden P. "The role of kidney transplantation as a component of integrated care for chronic kidney disease." Science Direct. 2020.Website
2019
Opiyo RO, Nyasulu PS, Olenja J, Zunza M, Nguyen KA, Bukania Z, Nabakwe E, Mbogo A, Were AO. "Factors associated with adherence to dietary prescription among adult patients with chronic kidney disease on hemodialysis in national referral hospitals in Kenya: a mixed-methods survey." Renal Replacement Therapy Journal. 2019. AbstractWebsite

Introduction: Adherence to dietary prescriptions among patients with chronic kidney disease is known to prevent
deterioration of kidney functions and slow down the risk for morbidity and mortality. This study determined factors
associated with adherence to dietary prescription among adult patients with chronic kidney disease on hemodialysis.
Methods: A mixed-methods study, using parallel mixed design, was conducted at the renal clinics and dialysis units at
the national teaching and referral hospitals in Kenya from September 2018 to January 2019. The study followed a
QUAN + qual paradigm, with quantitative survey as the primary method. Adult patients with chronic kidney disease on
hemodialysis without kidney transplant were purposively sampled for the quantitative survey. A sub-sample of
adult patients and their caregivers were purposively sampled for the qualitative survey. Numeric data were collected
using a structured, self-reported questionnaire using Open Data Kit “Collect software” while qualitative data were
collected using in-depth interview guides and voice recording. Analysis on STATA software for quantitative and
NVIV0 12 for qualitative data was conducted. The dependent variable, “adherence to diet prescription” was analyzed as a
binary variable. P values < 0.1 and < 0.05 were considered as statistically significant in univariate and multivariate logistic
regression models respectively. Qualitative data were thematically analyzed.
Results: Only 36.3% of the study population adhered to their dietary prescriptions. Factors that were independently
associated with adherence to diet prescriptions were “flexibility in the diets” (AOR 2.65, 95% CI 1.11–6.30, P
0.028), “difficulties in following diet recommendations” (AOR 0.24, 95% CI 0.13–0.46, P < 001), and “adherence
to limiting fluid intake” (AOR 9.74, 95% CI 4.90–19.38, P < 0.001).
Conclusions: For patients with chronic kidney disease on hemodialysis, diet prescriptions with less restrictions
and requiring minimal extra efforts and resources are more likely to be adhered to than the restrictive ones.
Patients who adhere to their fluid intake restrictions easily follow their diet prescriptions. Prescribed diets should be based
on the individual patient’s usual dietary habits and assessed levels of challenges in using such diets. Additionally, diet
adherence messages should be integrated with fluid limitation messages. Further research on understanding patients’
adherence to fluid restriction is also suggested.

Ndinya FO, Kayima JK, Magabe PC, McLigeyo SO, Were AJ, Odinya GO. "Haemodialysis vascular access function in dialysis patients at the Kenyatta National Hospital." African Journal of Nephrology. 2019;22(1):72-76. Abstract

Background: The number of patients requiring renal replacement therapy (RRT) worldwide has been on the rise.
Vascular access is the lifeline for these patients when haemodialysis (HD) is the treatment of choice. Access-related
morbidity is a leading cause of hospitalization so that the function and patency of access are essential for the optimal
management of patients. There is a need to recognize when a vascular access is dysfunctional because intervention
must maintain function as well as preserve future vascular access sites.
Methods: This was a cross-sectional study that evaluated the haemodialysis vascular access function in patients
undergoing chronic haemodialysis at the Kenyatta National Hospital, Nairobi, Kenya. Peak access blood flow rates,
urea reduction ratio (URR) and Kt/V were analysed in 150 patients.
Results: The temporary (non-tunnelled) central venous dialysis catheters had poor function, with only 48%
achieving a mean blood flow rate > 300 mL/min. The comparable rate for arteriovenous fistulae (AVF) was 88%
and for tunnelled dialysis catheters 82%. One-quarter of the patients had a URR < 65%. Higher mean blood flow
rates were associated with higher URR (P = 0.004) and Kt/V (P = 0.009) values. AVF stenosis was present in 12.5%
and thrombosis in 3% of patients. Aneurysms were the commonest AVF complication (47%) but were not
haemodynamically significant.
Conclusions: Tunnelled haemodialysis catheters offered adequate blood flows and achieved adequate delivered
dialysis, comparable to arteriovenous fistulae. Non-tunnelled catheters delivered poor blood flow rates and dialysis
dose. Greater blood flow rates were associated with a higher delivered dialysis dose. There is a need for routine
surveillance and affordable interventional procedures to prevent loss of vascular access.

JM.Kivai, Kayima JK, Were AO, Q.Zahida. "Impact of Pregnancy Related Acute Kidney Injury on foetalsurvival: a single Centre Experience in Kenya." IOSR Journal of Dental and Medical Sciences (IOSR-JDMS). 2019;18(7):13-17. AbstractWebsite

Abstract: Background: Pregnancy related acute kidney injury (PRAKI) is a heterogenous obstetric
complication, which can occur at any stage during pregnancy and in postpartumperiod. It often impacts
negatively on foetaloutcomes.
Objective: To determine impact of PRAKI on foetal outcomes at Kenyatta National Hospital (KNH), Nairobi.
Methods: We carried out a descriptive study on women with viable pregnancies, gestation age equal to, or
above 28 weeks and postpartum women within six weeks after delivery admitted in labour ward or the postnatal
wards at KNH. The study started afterit was approved by the KNH- University of Nairobi Ethics and
Research Committee.Patient management was at the discretion of attending clinician.Data was obtained
fromthe participants and their medical records. Followupwas until dischargeor for a maximum of two weeksfor
those who remained in the wards.
Results: Total participantswere 66 out of2068 admissions. Their mean age was 28years with peak age between
26-30 years.The prevalence of PRAKI was 3.2%. Sixty (91%) participants weredelivered andsix pregnancies
were ongoing past the follow-up period.The average gestation age at birth was 35 weeks. Forty-three (71.7%)
were life infants while 17(28.3%) were fresh still births. Comparing between participant women with PRAKI
and women without PRAKI, the ratio of fresh still births among participants was 1:4 and the ratio of fresh still
births among women without PRAKI was 1 in 23deliveries.
Conclusion: Wetherefore demonstrate that pregnancy related acute kidney injury was associated with a six (6)
fold increase in fresh still births at Kenyatta National Hospital in Kenya.
Key Words: PRAKI, KNH, Preterm births,Fresh still births,Nairobi, Kenya

2018
FA F, J K, CF O, A W, S N. "Dysglycaemia among kidney transplant recipients at a national referral hospital in Kenya." Journal of Kenya Association of Physicians. 2018;1(1).
2017
Soki KB, Were AJ, OGOLA EN, Nyale GM, Murage MM. "An echocardiographic evaluation of pulmonary pressures in hemodialysis patients at Kenyatta National Hospital, Nairobi, Kenya." East African Medical Journal. 2017;94(6). AbstractWebsite

Abstract

Background: A high prevalence of pulmonary hypertension (PH) in patients with end-stage renal disease (ESRD) has been noted. In these patients, PH increases morbidity and mortality and worsens prognosis post-renal transplant. Its aetiopathogenesis may be multifactorial, involving the process of haemodialysis itself.

Objective: To determine the prevalence of PH among patients with ESRD undergoing haemodialysis at Kenyatta National Hospital (KNH), using Doppler echocardiography

Design: 117 patients were consecutively recruited into this cross-sectional study.
Medical history was used to exclude patients with possible PH of known aetiology. Patients were examined for features of fluid overload. Each patient then underwent haemodialysis followed by echocardiography within two hours. Haemoglobin was measured.

Setting: The Renal Unit, KNH, a tertiary hospital in Nairobi

Subjects: Patients undergoing regular haemodialysis within the renal unit, thirteen years and above, who gave written informed consent or assent.

Results: 63.2% of the participants were male. Mean age was 44 years. Prevalence of PH among ESRD patients was 32.5%, with a median PASP of 47.3mmHg and a range of 36.1–79 mmHg. A strong association between PH and EF of less than 50%, as a marker of LV dysfunction, was demonstrated.

Conclusion: The prevalence of PH among end-stage renal disease patients was high. This suggests an indication for routinely screening haemodialysis patients for PH.

Keywords: ESRD: End stage renal disease, LV: Left ventricle, KNH: Kenyatta National Hospital, PASP: Pulmonary arterial systolic pressure, PH: Pulmonary Hypertension

2016
Kabinga DSK, O DAJ, Bhatt PKM, Kayima PJK, McLigeyo PSO. "Human Leucocyte Antigens (DRB1 *03, DRB1*04 and DQB1*02) Associated with Type 1 Diabetes Mellitus among 269 Kidney Graft Donors and Recipients in Kenya." International Journal of Sciences: Basic and Applied Research (IJSBAR). 2016:57-63. Abstract

This was a descriptive study which utilized the medical record
s for the kidney donors and recipients who had
been followed up
in
the kidney transplantation programme in Kenyatta National Hospital, Nairobi, Kenya.
Tissue typing is rarely performed routinely among our patients partially due to cost. It is with this in
mind that
we engaged in extraction of more information from the tissue typing data which have been used in kidney
transplantation programme in Kenyatta National Hospital, Nairobi Kenya. The data were extracted from the
medical records of patients who had undergone tissue typing for renal transplantation and were on follow up at
Kenyatta National Hospital. The study had been cleared by the Kenyatta National Hospital/University of
Nairobi Ethics Research Committee, number, P485/9/2013.
The medical records had tissue typing done from 2008 and 2013.
A total of 269 individuals’ human leucocyte
antigen typing were
utilized
. They comprised 134 kidney graft recipients
and 135 donors records
. T
he typing
had been performed using
serology
for class I and polymerase chain reaction for Class II respectively. The data
were analysed using Statistical Program for Social Sciences, calculating the frequencies of each individual for
HLA specificity and expressing it as a percentage of the total popu
lation of 269 individuals. For s
ome genes and
alleles associated
with
type 1 diabetes (
DRB1
*03, DRB1*04 and DQB1*02)
, there were 184/269 (68.4%) of
individual
s who carried genes and al
leles.
Eighty four (84) individuals had HLA
-DRB1*03 allele, 22 had
DRB1*04 while 78 had DQB1*02. Among 135 kidney graft donors, 39 (28.90%) carried HLA
-DRB1*03 and
14 (10.40%) carried DRB1*04. Among 134 kidney graft recipients, 45 (33.57%) had HLA
-DRB1*03
and 13
(9.70%) had HLA
-DRB1*04. Thirt
y-six (26.87%) had HLA
-DQB1*02.
There is increase in the prevalence of diabetes mellitus among other non
-communicable condition
s world over.
Diabetes has both nature and nurture as players for its causation. Genetics w
hich include human leucocyte
antigens have been liked with diabetes. Among our study population, HLA
-DRB1
*03, HLA
-DRB1*04 and
HLA-
DQB1*02 were prevalent and this may guide surveillance and care for both donors and recipients, as well
as inform the
care of our wider population.

2015
MN K, JK K, AJ W, SO ML, EN O. "Factors Associated with Uncontrolled Hypertension among Renal Transplant Recipients Attending Nephrology Clinics in Nairobi, Kenya." Journal Transplant. 2015. Abstractfactors_associated_with_uncontrolled_hypertension_among_renal_transplant_recipients_attending_nephrology_clinics_in_nairobi__kenya.pdf

Objective. To determine the factors associated with poor blood pressure control among renal transplant recipients in a resource-limited setting. Methods. A cross-sectional study was carried out on renal transplant recipients at the Kenyatta National Hospital. Sociodemographic details, blood pressure, urine albumin : creatinine ratio, and adherence using the MMAS-8 questionnaire were noted. Independent factors associated with uncontrolled hypertension were determined using logistic regression analysis. Results. 85 subjects were evaluated. Mean age was 42.4 (SD ± 12.2) years, with a male : female ratio of 1.9 : 1. Fifty-five patients (64.7%) had uncontrolled hypertension (BP ≥ 130/80 mmHg). On univariate analysis, male sex (OR 3.7, 95% CI 1.4-9.5, p = 0.006), higher levels of proteinuria (p = 0.042), and nonadherence to antihypertensives (OR 18, 95% CI 5.2-65.7, p < 0.001) were associated with uncontrolled hypertension. On logistic regression analysis, male sex (adjusted OR 4.6, 95% CI 1.1-19.0, p = 0.034) and nonadherence (adjusted OR 33.8, 95% CI 8.6-73.0, p < 0.001) were independently associated with uncontrolled hypertension. Conclusion. Factors associated with poor blood pressure control in this cohort were male sex and nonadherence to antihypertensives. Emphasis on adherence to antihypertensive therapy must be pursued within this population.

Kabinga S, Were AJO, Kayima JK, McLigeyo SO, Mbugua P, Ngigi J, Wambugu B, Wangombe N. "Living -Related Kidney Graft Donors Sociodemographic Characteristics and Recipients Clinical Characteristics in Kenya: A Single Centre Experience Kenyatta National Hospital 2010-2015 Audit ." International Journal of Sciences: Basic and Applied Research (IJSBAR). 2015:134-142. Abstract

This article provides summary of sociodemographic and clinical characteristics of the kidney transplant donors and recipients from 2010-2015 from Kenyatta national hospital, Nairobi, Kenya, East Africa. Only living-related
organ donation is practiced in Kenya.
Accelerated kidney transplantation activities picked up in Kenyatta National hospital from the 2010.
The duration from 2010-
2015 has seen more kidney transplantations undertaken in the hospital than the ones
done in the same hospital from 1984 when first transplantation
was performed in Kenya to 2009. The data were
extracted from manual medical records. There were about 120 kidney transplantations performed during this
period but only 113
complete
records were traceable.
There were 113 medical records for both kidney
graft donors and recipients from 2010-
2015. Demographic
characteristics for donors and recipients captured included age, sex, and donor
-recipient relationships. The mean
donor age was 32.94±8.52 years, median age of 32years with minimum donor age of 20 yea
rs and maximum of
54 years. Fifty five percent (54.90%) of the donors were males. Among the recipients, the mean age was
39.15
±12.68 years, median age of 36 years with the minimum recipient age of 14 years and maximum age of 66
years. Three in every four (
74.30%) of recipients were males. First degree relatives contributed 85.60% of all
the donors, with brothers and sisters to the recipients contributing almost equally (31.9% and 29.2%)
respectively
. The recipients clinical characteristics include the prim
ary disease, where hypertension and
glomerular diseases contributed 85.0% while diabetes mellitus contributed 13.30% of the documented primary
morbidity. Haemodialysis was the only modality of renal replacement therapy with a mean duration of
2.39±1.63 yea
rs and modes of 2 and 3 years. The most popular vascular access for dialysis was permanent
catheter (58.40%) with arteriovenous fistu
lae at 25.70%. Blood group O Rhesus positive was the commonest
among donors and recipients (70.80% and 53.10% respectively
). Blood transfusion was very common among
the recipients before and around transplantation. (51% and 68% respectively). The HLA
-A,
-B,
-DRB1
first and
second loci
match between the donors and recipients were zero match at 5.30%, one match at 9.70%, two
ma
tches at 11.50%, three matches at 38.10%, four matches at 20.40% five matches at 2.70% and six matches at
12.40%. All the transplantations were first kidney transplants
apart fro
m one case.
In our living
-related kidney transplantation programme, the donor
s are younger than recipients with males being
transplanted more than females. First degree relatives dominate the donation
. The commonest cause of the
ESRD was glomerular diseases and hypertension. The program shows plausible feasibility of organ transpla
nt
where the most po
pular modality of renal replace
ment therapy
.

2011
Ngigi J, Were A, Munene J, MUNGAI P. "Restarting a living donor kidney transplant Program in Kenya: 24 transplants performed in Less than one year.". In: 15th Congress of the European Society for Organ Transplantation .; 2011.
1996
AJ H, AJ W, HF B, EB M, I L, R. G. "Hypercalcaemia, hypermagnesaemia, hyperphosphataemia and hyperaluminaemia in CAPD: improvement in serum biochemistry by reduction in dialysate calcium and magnesium concentrations." Nephron. . 1996;72(1):52-8. Abstract

Phosphate binders are necessary to control hyperphosphataemia in the majority of dialysis patients. Whilst aluminium salts are efficient phosphate binders, their use is associated with toxic side effects. Calcium salts are a widely used alternative, but hypercalcaemia is a common side effect, limiting their use and raising concern about metastatic calcification. Reduction of the dialysis fluid calcium concentration has been shown to reduce hypercalcaemia in haemodialysis patients, with an associated decrease in serum PTH. We analysed the effect of reduced calcium/magnesium (1.25/0.25 mmol/l), 40 mmol/l lactate, PD fluid (PD4) on 11 CAPD patients with uncontrollable hypercalcaemia (> 2.65 mmol/l) and hyperphosphataemia (> 1.80 mmol/l). Only 1 patient remained hypercalcaemic, while phosphate fell in 6 patients (2.23 +/- 0.16 on no binder, to 1.68 +/- 0.08 mmol/l at 6 months (p < 0.05), but was unchanged in 5 (2.10 +/- 0.15 to 2.48 +/- 0.14 mmol/l [p = NS]). Overall mean calcium x phosphate product changed little. However, in a subgroup it fell significantly (p < 0.05). Geometric mean iPTH rose, but not significantly. The subgroup of patients whose calcium x phosphate product fell, exhibited a much smaller rise in iPTH than the others (57.3-73.2 vs. 52.8-167.1 pg/ml). 1.25-Dihydroxyvitamin D3 was subnormal in all patients. Mean serum magnesium fell from 1.24 +/- 0.06 to 0.89 +/- 0.04 mmol/l (p < 0.001), whilst mean serum bicarbonate rose significantly (25.2 +/- 0.4 to 28.9 +/- 1.2 mmol/l; p < 0.01). Withdrawal of aluminium-containing phosphate binders resulted in mean serum aluminium falling significantly from 31.1 +/- 5.7 at start of PD4 to 15.4 +/- 2.7 mu g/l at 6 months (p < 0.05). In summary, in around 50% of CAPD patients with persistent hypercalcaemia and hyperphosphataemia, reduction in PD fluid calcium can produce significant improvement in phosphate, reduction of calcium x phosphate product, and enable avoidance of aluminium-containing phosphate binders. Patients whose calcium and phosphate control remains poor, still benefit from the reduction, or cessation, of oral aluminium intake.

JK K, SO ML, AJ W, M L. "Kidney transplantation: recent medical experiences from the Kenyatta National Hospital, Nairobi." East Afr Med J. 1996;73(9):614-8. Abstract

Renal transplantation is not readily available in the majority of countries in Africa. It is expensive and difficult to sustain on the meagre funds allocated to health. We report our short experience with fifteen living donor recipients followed in our unit for at least 24 months, range 26 - 48 (mean 35 months) post-transplantation. The donors and recipients were mostly young adults with mean ages of 36.7 years and 32.6 years respectively. The majority of the donors and recipients were males. The donors in most cases were siblings. Within this time, one graft has been lost at one year and the patient restarted on haemodialysis. Three patients died, two within the first year, the third at 23 months after transplantation, all with functioning grafts. The one year graft and patient survival rates were 93% and 86.6% respectively. The second year graft survival rates remained at 93% and the patients survival rate 80%. The nature and frequency of complications seen in these patients is comparable to those in other centres. Of all medical complications, bacterial infections contributed 69.4% of all infections. Cardiovascular complications comprised 31.25% of the complications. Hypertension seen in 85.5% of the patients accounted for 65% of the cardiovascular complications. Acute rejections were common and occurred in seven patients. Transplantation is a viable mode of renal replacement therapy (RRT) in our environment. The practice should be supported to make it more readily available to the many young end stage renal failure (ESRF) patients.

1995
AJ W, SO ML. "Cost consideration in renal replacement therapy in Kenya." East Afr Med J. 1995;72(1):69-71. Abstract

End stage renal disease requiring renal replacement therapy is a common complication of several renal diseases that are seen in the tropics. World over, the costs of the various modalities of therapy that constitute renal replacement therapy, including hemodialysis, continuous ambulatory peritoneal dialysis and renal transplantation, is prohibitive. All the above modes of therapy are provided in Kenya, unlike most countries with similar level of socioeconomic development. This article analyses the factors behind the limited success that renal replacement therapy enjoys in Kenya, which is faced with more pressing basic problems of malnutrition and infection.

MCLIGEYO SO, KAYIMA JK, Were AJO. "Severe malaria in a renal transplant patient.". 1995.
1992
AJ W, LS O. "Acute renal failure as seen at Kenyatta National Hospital." East Afr Med J. 1992;69(2):110-3. Abstract

Forty seven patients with acute renal failure were studied prospectively over a two-year period at the Kenyatta National Hospital. There were 20 males and 27 females. The mortality rate was 40.4%. Most patients had medically oriented problems. Complications that were associated with a high mortality were infections and the presence of neuropsychiatric manifestations.

AJ W, A M, A T, R R, CD M, R G. "Netilmycin and vancomycin in the treatment of peritonitis in CAPD patients." Clin Nephrol.. 1992;37(4):209-13. Abstract

This study was undertaken to evaluate: 1. The efficacy of netilmycin and vancomycin as combined first line antimicrobial regime, compared to cefuroxime, in the treatment of peritonitis. 2. To measure the levels of netilmycin and vancomycin in the serum and dialysate. 3. To report on the use of this combination over a one year period and compare it with that of cefuroxime used during the previous one year.

AJ W, C S, JL A. "Oral herpes simplex virus type 1 infection following cadaveric renal transplantation in a young type 1 diabetic female. The role of acyclovir: a case report." East Afr Med J. 1992;69(12):709-11. Abstract

Oral infection with Herpes Simplex Virus (HSV) is a frequent and well documented complication in immunosuppressed individuals including patients on immunosuppressive medication. We report the development of severe oral infection with HSV type 1 in a 34 year old woman with type 1 diabetes mellitus and end stage renal disease (ESRD) following cadaveric renal transplantation at the Western General Hospital, Edinburgh. The role of acyclovir in therapy and chemoprophylaxis is discussed.

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