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Steenbeke M, Valkenburg S, Gryp T, Van Biesen W, Delanghe JR, Speeckaert MM, Glorieux G. Gut Microbiota and Their Derived Metabolites, a Search for Potential Targets to Limit Accumulation of Protein-Bound Uremic Toxins in Chronic Kidney Disease. Toxins (Basel) 2021; 13:toxins13110809. [PMID: 34822593 PMCID: PMC8625482 DOI: 10.3390/toxins13110809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 12/02/2022] Open
Abstract
Chronic kidney disease (CKD) is characterized by gut dysbiosis with a decrease in short-chain fatty acid (SCFA)-producing bacteria. Levels of protein-bound uremic toxins (PBUTs) and post-translational modifications (PTMs) of albumin increase with CKD, both risk factors for cardiovascular morbidity and mortality. The relationship between fecal metabolites and plasma concentrations of PBUTs in different stages of CKD (n = 103) was explored. Estimated GFR tends to correlate with fecal butyric acid (BA) concentrations (rs = 0.212; p = 0.032), which, in its turn, correlates with the abundance of SCFA-producing bacteria. Specific SCFAs correlate with concentrations of PBUT precursors in feces. Fecal levels of p-cresol correlate with its derived plasma UTs (p-cresyl sulfate: rs = 0.342, p < 0.001; p-cresyl glucuronide: rs = 0.268, p = 0.006), whereas an association was found between fecal and plasma levels of indole acetic acid (rs = 0.306; p = 0.002). Finally, the albumin symmetry factor correlates positively with eGFR (rs = 0.274; p = 0.005). The decreased abundance of SCFA-producing gut bacteria in parallel with the fecal concentration of BA and indole could compromise the intestinal barrier function in CKD. It is currently not known if this contributes to increased plasma levels of PBUTs, potentially playing a role in the PTMs of albumin. Further evaluation of SCFA-producing bacteria and SCFAs as potential targets to restore both gut dysbiosis and uremia is needed.
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Affiliation(s)
- Mieke Steenbeke
- Department of Internal Medicine and Pediatrics, Nephrology Unit, Ghent University Hospital, 9000 Ghent, Belgium
| | - Sophie Valkenburg
- Department of Internal Medicine and Pediatrics, Nephrology Unit, Ghent University Hospital, 9000 Ghent, Belgium
| | - Tessa Gryp
- Department of Internal Medicine and Pediatrics, Nephrology Unit, Ghent University Hospital, 9000 Ghent, Belgium
- Laboratory Bacteriology Research, Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium
| | - Wim Van Biesen
- Department of Internal Medicine and Pediatrics, Nephrology Unit, Ghent University Hospital, 9000 Ghent, Belgium
| | - Joris R Delanghe
- Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium
| | - Marijn M Speeckaert
- Department of Internal Medicine and Pediatrics, Nephrology Unit, Ghent University Hospital, 9000 Ghent, Belgium
- Research Foundation Flanders, 1000 Brussels, Belgium
| | - Griet Glorieux
- Department of Internal Medicine and Pediatrics, Nephrology Unit, Ghent University Hospital, 9000 Ghent, Belgium
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Favresse J, Delanghe J. High-resolution capillary electrophoresis for the determination of carbamylated albumin. Clin Chem Lab Med 2021; 60:229-234. [PMID: 34751528 DOI: 10.1515/cclm-2021-0926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Carbamylation is a non-enzymatic post-translational reaction of a primary amino group of a protein with isocyanate. The albumin carbamylation is a negative prognostic factor in chronic kidney disease (CKD) patients and induce charge difference implying an observed shift in electrophoretic mobility that can be measured through a symmetry factor (SF). METHODS The Helena V8 and the Sebia Capillarys 2 systems were used for all experiments. The effect of in vitro carbamylation on the SF by spiking increasing concentrations of potassium isocyanate (KCNO) in serum of three healthy volunteers was investigated. Theoretical plate numbers (N) as a surrogate of separation efficiency were also calculated and correlations between SF and renal function biomarkers were performed on 284 patients. RESULTS A dose-dependent impact of KCNO on the SF was observed for both methods with the Helena V8 being more sensitive. The mean N was significantly higher on the Helena V8 as compared to the Sebia Capillarys 2 (2,972 vs. 444.1, p<0.0001). The SF correlated significantly with eGFR (r=0.50, p<0.0001), creatinine (r=-0.31, p<0.0001) and urea (r=-0.34, p<0.0001) on the Helena V8. On the Sebia Capillarys 2, a significant correlation was only observed with eGFR (r=0.17, p=0.004). A better discrimination between CKD stages was also observed using the Helena V8. CONCLUSIONS Thanks to a higher mean N, the Helena V8 might offer new possibilities, including detection of carbamylated albumin through SF calculation. Further studies are still needed to confirm the interest of using this type of assays in clinical routine.
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Affiliation(s)
- Julien Favresse
- Department of Laboratory Medicine, Clinique St-Luc Bouge, Namur, Belgium.,Department of Pharmacy, Namur Research Institute for LIfes Sciences, University of Namur, Namur, Belgium
| | - Joris Delanghe
- Department of Clinical Chemistry, Ghent University Hospital, Gent, Belgium
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3
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Neuropathy - Exponent of Accelerated Involution in Uremia: The Role of Carbamylation. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2021. [DOI: 10.2478/sjecr-2021-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Premature loss of functional integrity of the nervous system in chronic renal failure (CRF) as a consequence of persistent biological activities of the general uremic milieu is almost identical to its structural and functional involution during the process of physiological ageing, but disproportionate and independent of chronological age. In the hyperuremic status of CRF (urea - carbamide), forced carbamylation, as a non-enzymatic post-translational modification (NEPTM) of proteins and amino acids, by changing their biological properties and decreasing proteolysis capacity, represents pathogenetic potential of intensified molecular ageing and accelerated, pathological involution. Physiological predisposition and the exposure of neuropathy before complications of other organs and organ systems in CRF, due to the simultaneous and mutually pathogenetically related uremic lesion and the tissue and vascular segment of the nervous system, direct interest towards proteomic analytical techniques of quantification of carbamylated products as biomarkers of uremic neurotoxicity. Hypothetically, identical to the already established applications of other NEPTM products in practice, they have the potential of clinical methodology in the evaluation of uremic neuropathy and its contribution to the general prediction, but also to the change of the conventional CRF classification. In addition, the identification and therapeutic control of the substrate of accelerated involution, responsible for the amplification of not only neurological but also general degenerative processes in CRF, is attractive in the context of the well-known attitude towards aging.
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De Bruyne S, Himpe J, Delanghe SE, Glorieux G, Van Biesen W, De Buyzere ML, Speeckaert MM, Delanghe JR. Carbamoylated Nail Proteins as Assessed by Near-Infrared Analysis are Associated with Load of Uremic Toxins and Mortality in Hemodialysis Patients. Toxins (Basel) 2020; 12:toxins12020083. [PMID: 31991867 PMCID: PMC7076796 DOI: 10.3390/toxins12020083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 12/12/2022] Open
Abstract
Carbamoylation is an important risk factor for accelerated atherogenesis and mortality in patients undergoing hemodialysis (HD). We intended to explore whether carbamoylation as assessed by near-infrared (NIR) analysis of nail proteins is associated with (a) plasma concentrations of representative uremic toxins and (b) mortality in HD patients. A total of 53 healthy volunteers and 84 consecutive HD patients were enrolled in this cross-sectional cohort study. Standard laboratory methods were used to measure routine parameters, whereas levels of uremic toxins were determined using reversed-phase high-performance liquid chromatography (RP-HPLC). Spectra of distal fingernail clippings were obtained using an Avantes NIR spectrometer and processed using chemometric data analysis. The second derivative of the peak intensity at 1494 nm attributed to N-H amide bands from NH2 of carbamoyl (-CONH2) groups was higher in HD patients than in control subjects (p < 0.0001). Peak intensity levels were associated with age and plasma levels of representative uremic toxins. Cox-regression analysis revealed a significant association with all-cause mortality, even after adjustment for age. In conclusion, our data revealed that carbamoylation as assessed by NIR analysis of nail proteins is associated with plasma concentrations of uremic toxins and also with mortality in HD patients. Further research to explore whether it is a surrogate marker or a hard indicator of mortality risk is warranted.
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Affiliation(s)
- Sander De Bruyne
- Department of Clinical Chemistry, Ghent University, 9000 Ghent, Belgium; (S.D.B.); (J.H.)
| | - Jonas Himpe
- Department of Clinical Chemistry, Ghent University, 9000 Ghent, Belgium; (S.D.B.); (J.H.)
| | - Sigurd E. Delanghe
- Department of Nephrology, Ghent University, 9000 Ghent, Belgium; (S.E.D.); (G.G.); (W.V.B.); (M.M.S.)
| | - Griet Glorieux
- Department of Nephrology, Ghent University, 9000 Ghent, Belgium; (S.E.D.); (G.G.); (W.V.B.); (M.M.S.)
| | - Wim Van Biesen
- Department of Nephrology, Ghent University, 9000 Ghent, Belgium; (S.E.D.); (G.G.); (W.V.B.); (M.M.S.)
| | - Marc L. De Buyzere
- Department of Cardiology, Heart Center, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Marijn M. Speeckaert
- Department of Nephrology, Ghent University, 9000 Ghent, Belgium; (S.E.D.); (G.G.); (W.V.B.); (M.M.S.)
- Research Foundation Flanders, 1000 Brussels, Belgium
| | - Joris R. Delanghe
- Department of Clinical Chemistry, Ghent University, 9000 Ghent, Belgium; (S.D.B.); (J.H.)
- Correspondence: ; Tel.: +32-9-332-29-56
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Rhode H, Muckova P, Büchler R, Wendler S, Tautkus B, Vogel M, Moore T, Grosskreutz J, Klemm A, Nabity M. A next generation setup for pre-fractionation of non-denatured proteins reveals diverse albumin proteoforms each carrying several post-translational modifications. Sci Rep 2019; 9:11733. [PMID: 31409882 PMCID: PMC6692309 DOI: 10.1038/s41598-019-48278-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/29/2019] [Indexed: 02/07/2023] Open
Abstract
Proteomic biomarker search requires the greatest analytical reproducibility and detailed information on altered proteoforms. Our protein pre-fractionation applies orthogonal native chromatography and conserves important features of protein variants such as native molecular weight, charge and major glycans. Moreover, we maximized reproducibility of sample pre-fractionation and preparation before mass spectrometry by parallelization and automation. In blood plasma and cerebrospinal fluid (CSF), most proteins, including candidate biomarkers, distribute into a multitude of chromatographic clusters. Plasma albumin, for example, divides into 15-17 clusters. As an example of our technique, we analyzed these albumin clusters from healthy volunteers and from dogs and identified cluster-typical modification patterns. Renal disease further modifies these patterns. In human CSF, we found only a subset of proteoforms with fewer modifications than in plasma. We infer from this example that our method can be used to identify and characterize distinct proteoforms and, optionally, enrich them, thereby yielding the characteristics of proteoform-selective biomarkers.
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Affiliation(s)
- Heidrun Rhode
- Institute of Biochemistry I, Nonnenplan 2-4, University Hospital Jena, 07740, Jena, Germany.
| | - Petra Muckova
- Institute of Biochemistry I, Nonnenplan 2-4, University Hospital Jena, 07740, Jena, Germany
| | - Rita Büchler
- Institute of Biochemistry I, Nonnenplan 2-4, University Hospital Jena, 07740, Jena, Germany.,Pharmachem Straße 1, Pharmachem Pößneck GmbH & Co. KG, 07381, Pößneck, Germany
| | - Sindy Wendler
- Institute of Biochemistry I, Nonnenplan 2-4, University Hospital Jena, 07740, Jena, Germany.,Institute of Microbiology, Am Klinikum 1, University Hospital Jena, 07747, Jena, Germany
| | - Bärbel Tautkus
- Institute of Biochemistry I, Nonnenplan 2-4, University Hospital Jena, 07740, Jena, Germany
| | - Michaela Vogel
- Institute of Biochemistry I, Nonnenplan 2-4, University Hospital Jena, 07740, Jena, Germany
| | - Thomas Moore
- Analytik Jena, Konrad-Zuse-Str.1, 07745, Jena, Germany
| | - Julian Grosskreutz
- Department of Neurology, Am Klinikum 1, University Hospital Jena, 07747, Jena, Germany
| | - Andree Klemm
- KfH Kuratorium für Dialyse und Nierentransplantation e.V., Ernst-Ruska-Ring 19, 07745, Jena, Germany
| | - Mary Nabity
- Department of Veterinary Pathobiology, College of Veterinary Medicine, 4467 TAMU, Texas A&M University, College Station, TX, 77843-4467, Texas, USA
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Padelli M, Labouret T, Labarre M, Le Reun E, Rouillé A, Kerspern H, Capaldo C, Chauvet J, Plée-Gautier E, Carré JL, Leven C. Systematic overestimation of human serum albumin by capillary zone electrophoresis method due to monoclonal immunoglobulin interferences. Clin Chim Acta 2019; 491:74-80. [PMID: 30641058 DOI: 10.1016/j.cca.2019.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The capillary zone electrophoresis method of albumin measurement is frequently used in monoclonal gammopathy patients but some studies suggest poor performances of the method in this population. The aim of this study was to analyse the impact of serum monoclonal immunoglobulins on human serum albumin determination by capillary zone electrophoresis method compared to other available methods. METHOD We prospectively measured albumin in 100 freshly collected non-frozen serum samples in a monoclonal gammopathy patients population, by using four different methods: the capillary zone electrophoresis method, the bromocresol purple dye method, the nephelometric method and the turbidimetric method. Differences in albumin values between the different methods were analysed with respect to serum monoclonal immunoglobulin concentration. These differences were further investigated by measuring albumin levels in human serum samples spiked with exogenous monoclonal immunoglobulins. RESULTS Human serum albumin difference values between capillary zone electrophoresis compared to immunonephelometry method are significantly correlated with increasing monoclonal immunoglobulins concentrations: regression analyses revealed a correlation coefficient r2 = 0.60 and a slope of 0.14 (0.12-0.17, 95% confidence interval). The capillary zone electrophoresis method overestimated serum albumin levels by up to 67% (12 g/L) when monoclonal immunoglobulin level was 63 g/L. The determination of albumin levels in human serum samples spiked with exogenous monoclonal immunoglobulins showed an overestimation of human serum albumin measurement by the capillary zone electrophoresis method proportional to the amount of monoclonal immunoglobulin added in the serum with a slope of 0.19 (0.18-0.20, 95% confidence interval). CONCLUSION Monoclonal immunoglobulins directly interfere with serum albumin measurement by the capillary zone electrophoresis method leading to a systematic overestimation of serum albumin concentrations proportional to the serum monoclonal immunoglobulin level.
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Affiliation(s)
- Maël Padelli
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France; Univ Brest, LIEN, F-29200 Brest, France.
| | - Théo Labouret
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France
| | - Marion Labarre
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France
| | - Eymeric Le Reun
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France
| | - Amélie Rouillé
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France
| | - Hélène Kerspern
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France
| | - Clément Capaldo
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France
| | - Juliette Chauvet
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France
| | - Emmanuelle Plée-Gautier
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France; Univ Brest, LIEN, F-29200 Brest, France
| | - Jean-Luc Carré
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France; Univ Brest, LIEN, F-29200 Brest, France
| | - Cyril Leven
- Department of Biochemistry and Pharmaco-Toxicology, University Hospital of Brest, Brest, France; Univ Brest, LIEN, F-29200 Brest, France
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Padelli M, Leven C, Le Reun E, Labouret T, Galakhoff N, Labarre M, Rouillé A, Kerspern H, Lapègue M, Chauvet J, Plée-Gautier E, Carré JL. Is capillary zone electrophoresis a suitable method for estimating serum albumin: A comparison of four methods. Clin Chim Acta 2018; 487:250-255. [DOI: 10.1016/j.cca.2018.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/03/2018] [Accepted: 10/03/2018] [Indexed: 01/03/2023]
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Abstract
Protein carbamylation is a nonenzymatic posttranslational protein modification that can be driven, in part, by exposure to urea's dissociation product, cyanate. In humans, when kidney function is impaired and urea accumulates, systemic protein carbamylation levels increase. Additional mediators of protein carbamylation have been identified including inflammation, diet, smoking, circulating free amino acid levels, and environmental exposures. Carbamylation reactions on proteins are capable of irreversibly changing protein charge, structure, and function, resulting in pathologic molecular and cellular responses. Carbamylation has been mechanistically linked to the biochemical pathways implicated in atherosclerosis, dysfunctional erythropoiesis, kidney fibrosis, autoimmunity, and other pathological domains highly relevant to patients with chronic kidney disease. In this review, we describe the biochemical impact of carbamylation on human proteins, the mechanistic role carbamylation can have on clinical outcomes in kidney disease, the clinical association studies of carbamylation in chronic kidney disease, including patients on dialysis, and the promise of therapies aimed at reducing carbamylation burden in this vulnerable patient population.
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Affiliation(s)
- Joshua Long
- Nephrology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Xavier Vela Parada
- Nephrology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Sahir Kalim
- Nephrology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Jaisson S, Pietrement C, Gillery P. Protein Carbamylation: Chemistry, Pathophysiological Involvement, and Biomarkers. Adv Clin Chem 2018; 84:1-38. [PMID: 29478512 DOI: 10.1016/bs.acc.2017.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Protein carbamylation refers to a nonenzymatic modification, which consists in the binding of isocyanic acid on protein functional groups. This reaction is responsible for the alteration in structural and functional properties of proteins, which participate in their molecular aging. Protein molecular aging is now considered a molecular substratum for the development of chronic and inflammatory diseases, including atherosclerosis, chronic kidney disease, or rheumatoid arthritis. As a consequence, carbamylation-derived products have been proposed as interesting biomarkers in various pathological contexts and appropriate analytical methods have been developed for their quantification in biological fluids. The purpose of this review is (i) to describe the biochemical bases of the carbamylation reaction, (ii) to explain how it contributes to protein molecular aging, (iii) to provide evidence of its involvement in aging and chronic diseases, and (iv) to list the available biomarkers of carbamylation process and the related analytical methods.
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10
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A capillary zone electrophoresis method for detection of Apolipoprotein C-III glycoforms and other related artifactually modified species. J Chromatogr A 2018; 1532:238-245. [DOI: 10.1016/j.chroma.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/30/2017] [Accepted: 12/01/2017] [Indexed: 11/22/2022]
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11
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Delanghe S, Delanghe JR, Speeckaert R, Van Biesen W, Speeckaert MM. Mechanisms and consequences of carbamoylation. Nat Rev Nephrol 2017; 13:580-593. [PMID: 28757635 DOI: 10.1038/nrneph.2017.103] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Protein carbamoylation is a non-enzymatic post-translational modification that binds isocyanic acid, which can be derived from the dissociation of urea or from the myeloperoxidase-mediated catabolism of thiocyanate, to the free amino groups of a multitude of proteins. Although the term 'carbamoylation' is usually replaced by the term "carbamylation" in the literature, carbamylation refers to a different chemical reaction (the reversible interaction of CO2 with α and ε-amino groups of proteins). Depending on the altered molecule (for example, collagen, erythropoietin, haemoglobin, low-density lipoprotein or high-density lipoprotein), carbamoylation can have different pathophysiological effects. Carbamoylated proteins have been linked to atherosclerosis, lipid metabolism, immune system dysfunction (such as inhibition of the classical complement pathway, inhibition of complement-dependent rituximab cytotoxicity, reduced oxidative neutrophil burst, and the formation of anti-carbamoylated protein antibodies) and renal fibrosis. In this Review, we discuss the carbamoylation process and evaluate the available biomarkers of carbamoylation (for example, homocitrulline, the percentage of carbamoylated albumin, carbamoylated haemoglobin, and carbamoylated low-density lipoprotein). We also discuss the relationship between carbamoylation and the occurrence of cardiovascular events and mortality in patients with chronic kidney disease and assess the effects of strategies to lower the carbamoylation load.
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Affiliation(s)
- Sigurd Delanghe
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Joris R Delanghe
- Department of Clinical Chemistry, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Reinhart Speeckaert
- Department of Clinical Chemistry, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Marijn M Speeckaert
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
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