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Shbeer AM, Ahmed Robadi I. The role of Interleukin-21 in autoimmune Diseases: Mechanisms, therapeutic Implications, and future directions. Cytokine 2024; 173:156437. [PMID: 37972478 DOI: 10.1016/j.cyto.2023.156437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
IL-21 is a multifunctional cytokine that regulates the functional activity of various immune cells. Initial studies have shown that IL-21 can influence the differentiation, proliferation and function of T and B cells, as well as promote the maturation and increase the cytotoxicity of CD8 + T cells and NK cells. During humoral immune responses, IL-21 has significant effects on B cell activation, differentiation and apoptosis. In addition, IL-21 promotes the differentiation of both naive and memory B cells, ultimately leading to the activation of plasma cells. The function of IL-21 in the immune system is complex, as it has the ability to either stimulate or inhibit immune responses. in addition, IL-21 facilitates the differentiation of naive and memory B cells into plasma cells. The functionality of IL-21 in the immune system is diverse, as it has the ability to stimulate or inhibit immune responses. This cytokine has been implicated in several diseases including cancer, allergies and autoimmune diseases. Research has suggested that this cytokine is involved in the development of autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. Several studies have suggested that inhibition of IL-21 has a therapeutic effect on autoimmune diseases. Therefore, targeting both the cytokine's receptor and IL-21 in autoimmune diseases may be an effective approach to reduce the severity of the disease or to treat it. This review will examine the biological effects of IL-21 on various immune cells and the role of the cytokine in autoimmune diseases.
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Affiliation(s)
- Abdullah M Shbeer
- Department of Surgery, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia.
| | - Ibrahim Ahmed Robadi
- Department of pathology, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
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Alqahtani B, Daghestani M, Omair MA, Alhamad EH, Tashkandy Y, Othman N, Al Shahrani K, Paramasivam MP, Alenzi F, Halwani R, Alkhulaifi FM, Alomar SY. Association of Inflammatory Cytokine Levels with Extra Glandular Manifestations, Fatigue, and Disease Activity in Primary Sjögren's Syndrome in Saudi Patients: A Cross-Sectional Study. Diagnostics (Basel) 2023; 13:3036. [PMID: 37835779 PMCID: PMC10572739 DOI: 10.3390/diagnostics13193036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Primary Sjögren's syndrome (pSS) is an autoimmune disease that can cause fatigue and extraglandular manifestations (EGMs). pSS is associated with cytokine network dysregulation, which may be related to the immune-mediated destruction of exocrine glands. OBJECTIVE We determined cytokine levels and their relationship to EGMs, the European League Against Rheumatism (EULAR) Sjögren's syndrome disease activity index (ESSDAI), and fatigue in Saudi patients with pSS. METHODS This study was a cross-sectional, single-center study. We included forty-one patients and 71 controls. Serum samples were collected from random healthy people and pSS patients who were followed in the rheumatology and pulmonary clinics of King Saud University Medical City in Riyadh, Saudi Arabia. Levels of the frequently studied cytokines were measured using Luminex xMAP technology. Each ESSDAI score and EGM were recorded, and the Arabic version of the fatigue severity scale (FSS) was applied to assess fatigue. The main outcome measures were cytokine levels in pSS Saudi patients using/not using immune-suppressive medications (ISMs). RESULTS Thirty-six (87.8%) patients had one or more EGMs, and the mean ESSDAI score was 9.95 ± 7.73. There was a significant decrease in TNFα and IL-21 levels in the pSS group compared to those in the control group (p = 0.034 and p < 0.001, respectively), whereas IL-12 levels were significantly elevated in the pSS group (p = 0.002). Cytokine levels in patients who used ISMs were the same as those in patients who did not use medications. Decreased IL-1β (p = 0.014), IL-2 (p = 0.035), IL-6 (p = 0.014), and IL-35 (p = 0.010) levels were observed in patients who had EGMs. Patients who had low disease activity exhibited low IL-10 (p = 0.018) and high IFN-α (p = 0.049), IFN-β (p = 0.049), IL-1β (p = 0.006), and IL-35 (p = 0.032) levels compared to patients with high disease activity. A negative association between a positive fatigue score and IL-1β (p = 0.010), IL-2 (p = 0.037), IFN-α (p = 0.025), TNFα (p = 0.030), IL-17 (p = 0.029), IL-12 (p = 0.046), and IL-21 (p = 0.005) levels was found. CONCLUSIONS Cytokine profiles correlate with EGMs, ESSDAI, and fatigue. Patients with controlled disease activity have a normal cytokine profile that is similar to that of controls.
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Affiliation(s)
- Bashaer Alqahtani
- Department of Zoology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (B.A.); (M.D.)
| | - Maha Daghestani
- Department of Zoology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (B.A.); (M.D.)
| | - Mohammed A. Omair
- Rheumatology Unit, Department of Medicine, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Esam H. Alhamad
- Department of Medicine, Division of Pulmonary Medicine, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Yusra Tashkandy
- Department of Statistics and Operations Research, College of Sciences, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Nashwa Othman
- Central Laboratory, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Khalid Al Shahrani
- Rheumatology Division, Department of Medicine, Ad Diriyah Hospital, Ministry of Health, Riyadh 13717, Saudi Arabia;
| | - Muthurajan P. Paramasivam
- Pulmonary Division, Department of Medicine, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Fahidah Alenzi
- Department of Clinical Science, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia;
| | - Rabih Halwani
- Department of Clinical Sciences, Sharjah Institute for Medical Research (SIMR), College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates;
| | - Fadwa M. Alkhulaifi
- Biology Department, College of Science, Imam Abdulrahman bin Faisal University, Dammam 34212, Saudi Arabia;
| | - Suliman Yousef Alomar
- Department of Zoology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia; (B.A.); (M.D.)
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Guggino G, Rizzo C, Mohammadnezhad L, Lo Pizzo M, Lentini VL, Di Liberto D, La Barbera L, Raimondo S, Shekarkar Azgomi M, Urzì O, Berardicurti O, Campisi G, Alessandro R, Giacomelli R, Dieli F, Ciccia F. Possible role for IL-40 and IL-40-producing cells in the lymphocytic infiltrated salivary glands of patients with primary Sjögren's syndrome. RMD Open 2023; 9:rmdopen-2022-002738. [PMID: 37137540 PMCID: PMC10163598 DOI: 10.1136/rmdopen-2022-002738] [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: 09/15/2022] [Accepted: 03/31/2023] [Indexed: 05/05/2023] Open
Abstract
OBJECTIVES Aim of this study was to investigate the expression of interleukin (IL)-40, a new cytokine associated with B cells homoeostasis and immune response, in primary Sjögren syndrome (pSS) and in pSS-associated lymphomas. METHODS 29 patients with pSS and 24 controls were enrolled. Minor salivary gland (MSG) biopsies from patients, controls and parotid gland biopsies from pSS-associated lymphoma were obtained. Quantitative gene expression analysis by TaqMan real-time PCR and immunohistochemistry for IL-40 were performed on MSG. MSG cellular sources of IL-40 were determined by flow-cytometry and immunofluorescence. Serum concentration of IL-40 was assessed by ELISA and cellular sources of IL-40 were determined by flow-cytometry. An in vitro assay with recombinant IL-40 (rIL-40) was performed to detect the effect on cytokine production from peripheral blood mononuclear cells (PBMCs). RESULTS IL-40 was significantly increased in the lymphocytic infiltrated MSG of patients with pSS and correlated with focus score and with IL-4 and transforming growth factor-β expression. In addition, IL-40 was increased in the serum of pSS and its levels correlated with the EULAR Sjögren's Syndrome Disease Activity Index score. B cells from patients were shown to be the major source of IL-40 at both tissue and peripheral level. PBMCs from patients, exposed to rIL-40 in vitro, released proinflammatory cytokines, specifically interferon-γ from B cells and T-CD8+ and tumour necrosis factor-α and IL-17 from both T-CD4+ and T-CD8+. IL-40 expression in parotid glands of pSS-associated lymphomas was also increased. Moreover, IL-40-driven NETosis was evidenced in neutrophils obtained from pSS. CONCLUSION Our results suggest that IL-40 may play a role in pSS pathogenesis and pSS-associated lymphomas.
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Affiliation(s)
- Giuliana Guggino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Rheumatology section - "P. Giaccone", University of Palermo, Palermo, Sicilia, Italy
| | - Chiara Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Rheumatology section - "P. Giaccone", University of Palermo, Palermo, Sicilia, Italy
| | - Leila Mohammadnezhad
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, Immunology Section, University of Palermo, Palermo, Sicilia, Italy
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, Palermo, Sicilia, Italy
| | - Marianna Lo Pizzo
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, Immunology Section, University of Palermo, Palermo, Sicilia, Italy
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, Palermo, Sicilia, Italy
| | | | - Diana Di Liberto
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, Immunology Section, University of Palermo, Palermo, Sicilia, Italy
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, Palermo, Sicilia, Italy
| | - Lidia La Barbera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Rheumatology section - "P. Giaccone", University of Palermo, Palermo, Sicilia, Italy
| | - Stefania Raimondo
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, Section of Biology and Genetics, University of Palermo, Palermo, Sicilia, Italy
| | - Mojtaba Shekarkar Azgomi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Rheumatology section - "P. Giaccone", University of Palermo, Palermo, Sicilia, Italy
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, Palermo, Sicilia, Italy
| | - Ornella Urzì
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, Section of Biology and Genetics, University of Palermo, Palermo, Sicilia, Italy
| | - Onorina Berardicurti
- Unit of Allergology, Immunology, Rheumatology, Campus Bio-Medico University Hospital, Roma, Lazio, Italy
| | - Giuseppina Campisi
- Department of Surgical, Oncological and Oral Sciences - "P. Giaccone" University Hospital, University of Palermo, Palermo, Sicilia, Italy
| | - Riccardo Alessandro
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, Section of Biology and Genetics, University of Palermo, Palermo, Sicilia, Italy
| | - Roberto Giacomelli
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Campus Bio-Medico University Hospital, Roma, Lazio, Italy
| | - Francesco Dieli
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, Immunology Section, University of Palermo, Palermo, Sicilia, Italy
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, Palermo, Sicilia, Italy
| | - Francesco Ciccia
- Department of Precision Medicine, University of Campania Luigi Vanvitelli School of Medicine and Surgery, Napoli, Campania, Italy
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Zandonella Callegher S, Giovannini I, Zenz S, Manfrè V, Stradner MH, Hocevar A, Gutierrez M, Quartuccio L, De Vita S, Zabotti A. Sjögren syndrome: looking forward to the future. Ther Adv Musculoskelet Dis 2022; 14:1759720X221100295. [PMID: 35634352 PMCID: PMC9131387 DOI: 10.1177/1759720x221100295] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/26/2022] [Indexed: 12/25/2022] Open
Abstract
Primary Sjögren’s syndrome (pSS) is a heterogeneous disease characterised by a wide spectrum of manifestations that vary according to the different stages of the disease and among different subsets of patients. The aim of this qualitative literature review is to summarise the recent advances that have been reported in pSS, ranging from the early phases to the established disease and its complications. We analysed the diagnostic, prognostic, and management aspects of pSS, with a look into future clinical and research developments. The early phases of pSS, usually antedating diagnosis, allow us to investigate the pathophysiology and risk factors of the overt disease, thus allowing better and timely patient stratification. Salivary gland ultrasound (SGUS) is emerging as a valid complementary, or even alternative, tool for histopathology in the diagnosis of pSS, due to a standardised scoring system with good agreement and performance. Other promising innovations include the application of artificial intelligence to SGUS, ultrasound-guided core needle biopsy, and a wide array of novel diagnostic and prognostic biomarkers. Stratifying pSS patients through the integration of clinical, laboratory, imaging, and histopathological data; differentiating between activity-related and damage-related manifestations; and identifying patients at higher risk of lymphoma development are essential steps for an optimal management and individualised treatment approach. As new treatment options are emerging for both glandular and systemic manifestations, there is a need for a more reliable treatment response evaluation. pSS is a complex and heterogeneous disease, and many distinct aspects should be considered in the different stages of the disease and subsets of patients. In recent years, efforts have been made to improve our understanding of the disease, and certainly in the coming years, some of these novelties will become part of our routine clinical practice, thus improving the management of pSS patients.
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Affiliation(s)
| | - Ivan Giovannini
- Rheumatology Clinic, Department of Medicine, University of Udine, c/o Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Sabine Zenz
- Division of Rheumatology and Immunology, Medical University Graz, Graz, Austria
| | - Valeria Manfrè
- Rheumatology Clinic, Department of Medicine, University of Udine, c/o Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Martin H. Stradner
- Division of Rheumatology and Immunology, Medical University Graz, Graz, Austria
| | - Alojzija Hocevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Marwin Gutierrez
- Division of Musculoskeletal and Rheumatic Diseases, Instituto Nacional de Rehabilitacion, Mexico City, Mexico
- Rheumatology Center of Excellence, Mexico City, Mexico
| | - Luca Quartuccio
- Rheumatology Clinic, Department of Medicine, University of Udine, c/o Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Salvatore De Vita
- Rheumatology Clinic, Department of Medicine, University of Udine, c/o Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Alen Zabotti
- Rheumatology Clinic, Department of Medicine, University of Udine, c/o Azienda Sanitaria Universitaria Friuli Centrale, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
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Das N, Menon NG, de Almeida LGN, Woods PS, Heynen ML, Jay GD, Caffery B, Jones L, Krawetz R, Schmidt TA, Dufour A. Proteomics Analysis of Tears and Saliva From Sjogren's Syndrome Patients. Front Pharmacol 2021; 12:787193. [PMID: 34950038 PMCID: PMC8689002 DOI: 10.3389/fphar.2021.787193] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/02/2021] [Indexed: 12/17/2022] Open
Abstract
Sjogren's syndrome (SS) is characterized by dysfunctional mucous membranes and dysregulated moisture-secreting glands resulting in various symptoms, including dry mouth and dry eyes. Here, we wanted to profile and compare the tear and saliva proteomes of SS patients to healthy controls. Tear and saliva samples were collected and subjected to an isotopic dimethylation labeling shotgun proteomics workflow to identify alterations in protein levels. In tear samples, we identified 83 upregulated and 112 downregulated proteins. Pathway enrichment analysis of the changing proteins by Metascape identified leukocyte transendothelial migration, neutrophil degranulation, and post-translation protein phosphorylation in tears of SS patients. In healthy controls' tears, an enrichment for proteins related to glycolysis, amino acid metabolism and apoptotic signaling pathway were identified. In saliva, we identified 108 upregulated and 45 downregulated proteins. Altered pathways in SS patients' saliva included cornification, sensory perception to taste and neutrophil degranulation. In healthy controls' saliva, an enrichment for proteins related to JAK-STAT signaling after interleukin-12 stimulation, phagocytosis and glycolysis in senescence were identified. Dysregulated protease activity is implicated in the initiation of inflammation and immune cell recruitment in SS. We identified 20 proteases and protease inhibitors in tears and 18 in saliva which are differentially expressed between SS patients and healthy controls. Next, we quantified endogenous proteoglycan 4 (PRG4), a mucin-like glycoprotein, in tear wash and saliva samples via a bead-based immune assay. We identified decreased levels of PRG4 in SS patients' tear wash compared to normal samples. Conversely, in saliva, we found elevated levels of PRG4 concentration and visualized PRG4 expression in human parotid gland via immunohistological staining. These findings will improve our mechanistic understanding of the disease and changes in SS patients' protein expression will help identify new potential drug targets. PRG4 is among the promising targets, which we identified here, in saliva, for the first time.
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Affiliation(s)
- Nabangshu Das
- Departments of Physiology and Pharmacology and Kinesiology, University of Calgary, Calgary, AB, Canada
- McCaig Institute, University of Calgary, Calgary, AB, Canada
| | - Nikhil G. Menon
- Department of Biomedical Engineering, School of Dental Medicine, UConn Health, Farmington, CT, United States
| | - Luiz G. N. de Almeida
- Departments of Physiology and Pharmacology and Kinesiology, University of Calgary, Calgary, AB, Canada
- McCaig Institute, University of Calgary, Calgary, AB, Canada
| | - Paige S. Woods
- Department of Emergency Medicine, Warren Alpert Medical School and School of Engineering, Brown University, Providence, RI, United States
| | - Miriam L. Heynen
- Centre for Ocular Research and Education (CORE), School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
| | - Gregory D. Jay
- Department of Emergency Medicine, Warren Alpert Medical School and School of Engineering, Brown University, Providence, RI, United States
| | | | - Lyndon Jones
- Centre for Ocular Research and Education (CORE), School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
| | - Roman Krawetz
- McCaig Institute, University of Calgary, Calgary, AB, Canada
- Department of Cell Biology and Anatomy, University of Calgary, Calgary, AB, Canada
| | - Tannin A. Schmidt
- McCaig Institute, University of Calgary, Calgary, AB, Canada
- Department of Biomedical Engineering, School of Dental Medicine, UConn Health, Farmington, CT, United States
| | - Antoine Dufour
- Departments of Physiology and Pharmacology and Kinesiology, University of Calgary, Calgary, AB, Canada
- McCaig Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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López‐Villalobos EF, Muñoz‐Valle JF, Palafox‐Sánchez CA, García‐Arellano S, Martínez‐Fernández DE, Orozco‐Barocio G, García‐Espinoza JA, Oregon‐Romero E. Cytokine profiles and clinical characteristics in primary Sjögren´s syndrome patient groups. J Clin Lab Anal 2021; 35:e23629. [PMID: 33070375 PMCID: PMC7891511 DOI: 10.1002/jcla.23629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Primary Sjögren's syndrome (pSS) is an autoimmune disease characterized by a lymphocytic infiltrate in salivary glands driving to epithelial damage. The pSS patients present heterogenic clinical and serological characteristics. This heterogenicity could be due to the cytokine microenvironment. Cytokine levels have been analyzed and reported individually, showing controversial results; for that reason, we considered essential to evaluate a cluster of cytokines and relate them with antibody levels and clinical characteristics to find pSS subgroups. METHODS Ninety-nine pSS patients, diagnosed by the 2016 ACR/EULAR classification criteria, and 76 control subjects (CS) were included. Cytokine quantification was performed by Multiplex assay. Principal component analysis (PCA) was realized, and the K-mean test was used to identify clusters/groups. Groups were analyzed by the Kruskal-Wallis test and the Bonferroni test. RESULTS Higher IFN-γ, IL-17F, IL-21, IL-23, IL-4, and IL-31 levels were observed in pSS patients in comparison with control subjects. PCA analysis showed three groups. The severe group was characterized by higher cytokine concentrations as well as an increase in clinical parameters such as antibody levels, damage index score, and others. The moderate group presented intermediate severity; meanwhile, the mild group presented the lowest severity. CONCLUSION Cluster analysis revealed three groups that were different in cytokine levels and clinical parameters in which the mild group was defined by lower severity, the moderate group with intermediate severity, and the severe group with higher severity. This analysis could help subclassify the primary Sjögren syndrome patients for a better understanding of the clinical phenotype that impacts the treatment approach.
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Affiliation(s)
- Erika Fabiola López‐Villalobos
- Instituto de Investigación en Ciencias Biomédicas (IICB)Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
- Doctorado en Ciencias BiomédicasCentro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
| | - José Francisco Muñoz‐Valle
- Instituto de Investigación en Ciencias Biomédicas (IICB)Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
| | - Claudia Azucena Palafox‐Sánchez
- Instituto de Investigación en Ciencias Biomédicas (IICB)Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
| | - Samuel García‐Arellano
- Instituto de Investigación en Ciencias Biomédicas (IICB)Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
| | - Diana Emilia Martínez‐Fernández
- Instituto de Investigación en Ciencias Biomédicas (IICB)Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
- Doctorado en Ciencias BiomédicasCentro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
| | | | - José Antonio García‐Espinoza
- Instituto de Investigación en Ciencias Biomédicas (IICB)Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
- Doctorado en Ciencias BiomédicasCentro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
| | - Edith Oregon‐Romero
- Instituto de Investigación en Ciencias Biomédicas (IICB)Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
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