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Hu W, Dai Y, Liu F, Yang T, Wang Y, Shen Y, Zhou W, Wu D, Gu L, Zhang M, Zhou Y. Assessing renal interstitial fibrosis using compartmental, non-compartmental, and model-free diffusion MRI approaches. Insights Imaging 2024; 15:156. [PMID: 38900336 PMCID: PMC11189852 DOI: 10.1186/s13244-024-01736-2] [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: 12/19/2023] [Accepted: 06/02/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE To assess renal interstitial fibrosis (IF) using diffusion MRI approaches, and explore whether corticomedullary difference (CMD) of diffusion parameters, combination among MRI parameters, or combination with estimated glomerular filtration rate (eGFR) benefit IF evaluation. METHODS Forty-two patients with chronic kidney disease were included, undergoing MRI examinations. MRI parameters from apparent diffusion coefficient (ADC), intra-voxel incoherent motion (IVIM), diffusion kurtosis imaging (DKI), and diffusion-relaxation correlated spectrum imaging (DR-CSI) were obtained both for renal cortex and medulla. CMD of these parameters was calculated. Pathological IF scores (1-3) were obtained by biopsy. Patients were divided into mild (IF = 1, n = 23) and moderate-severe fibrosis (IF = 2-3, n = 19) groups. Group comparisons for MRI parameters were performed. Diagnostic performances were assessed by the receiver operator's curve analysis for discriminating mild from moderate-severe IF patients. RESULTS Significant inter-group differences existed for cortical ADC, IVIM-D, IVIM-f, DKI-MD, DR-CSI VB, and DR-CSI VC. Significant inter-group differences existed in ΔADC, ΔMD, ΔVB, ΔVC, ΔQB, and ΔQC. Among the cortical MRI parameters, VB displayed the highest AUC = 0.849, while ADC, f, and MD also showed AUC > 0.8. After combining cortical value and CMD, the diagnostic performances of the MRI parameters were slightly improved except for IVIM-D. Combining VB with f brings the best performance (AUC = 0.903) among MRI bi-variant models. A combination of cortical VB, ΔADC, and eGFR brought obvious improvement in diagnostic performance (AUC 0.963 vs 0.879, specificity 0.826 vs 0.896, and sensitivity 1.000 vs 0.842) than eGFR alone. CONCLUSION Our study shows promising results for the assessment of renal IF using diffusion MRI approaches. CRITICAL RELEVANCE STATEMENT Our study explores the non-invasive assessment of renal IF, an independent and effective predictor of renal outcomes, by comparing and combining diffusion MRI approaches including compartmental, non-compartmental, and model-free approaches. KEY POINTS Significant difference exists for diffusion parameters between mild and moderate-severe IF. Generally, cortical parameters show better performance than corresponding CMD. Bi-variant model lifts the diagnostic performance for assessing IF.
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Affiliation(s)
- Wentao Hu
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongming Dai
- School of Biomedical Engineering, ShanghaiTech University, Shanghai, China
| | - Fang Liu
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianshu Yang
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yao Wang
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiwei Shen
- Department of Nephrology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenyan Zhou
- Department of Nephrology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongmei Wu
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronics Science, East China Normal University, Shanghai, China
| | - Leyi Gu
- Department of Nephrology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minfang Zhang
- Department of Nephrology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yan Zhou
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Zhou SP, Wang Q, Chen P, Zhai X, Zhao J, Bai X, Li L, Guo HP, Ning XY, Zhang XJ, Ye HY, Dong ZY, Chen XM, Wang HY. Assessment of the Added Value of Intravoxel Incoherent Motion Diffusion-Weighted MR Imaging in Identifying Non-Diabetic Renal Disease in Patients With Type 2 Diabetes Mellitus. J Magn Reson Imaging 2024; 59:1593-1602. [PMID: 37610209 DOI: 10.1002/jmri.28973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/10/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Identification of non-diabetic renal disease (NDRD) in patients with type 2 diabetes mellitus (T2DM) may help tailor treatment. Intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) is a promising tool to evaluate renal function but its potential role in the clinical differentiation between diabetic nephropathy (DN) and NDRD remains unclear. PURPOSE To investigate the added role of IVIM-DWI in the differential diagnosis between DN and NDRD in patients with T2DM. STUDY TYPE Prospective. POPULATION Sixty-three patients with T2DM (ages: 22-69 years, 17 females) confirmed by renal biopsy divided into two subgroups (28 DN and 35 NDRD). FIELD STRENGTH/SEQUENCE 3 T/ T2 weighted imaging (T2WI), and intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI). ASSESSMENT The parameters derived from IVIM-DWI (true diffusion coefficient [D], pseudo-diffusion coefficient [D*], and pseudo-diffusion fraction [f]) were calculated for the cortex and medulla, respectively. The clinical indexes related to renal function (eg cystatin C, etc.) and diabetes (eg diabetic retinopathy [DR], fasting blood glucose, etc.) were measured and calculated within 1 week before MRI scanning. The clinical model based on clinical indexes and the IVIM-based model based on IVIM parameters and clinical indexes were established and evaluated, respectively. STATISTICAL TESTS Student's t-test; Mann-Whitney U test; Fisher's exact test; Chi-squared test; Intraclass correlation coefficient; Receiver operating characteristic analysis; Hosmer-Lemeshow test; DeLong's test. P < 0.05 was considered statistically significant. RESULTS The cortex D*, DR, and cystatin C values were identified as independent predictors of NDRD in multivariable analysis. The IVIM-based model, comprising DR, cystatin C, and cortex D*, significantly outperformed the clinical model containing only DR, and cystatin C (AUC = 0.934, 0.845, respectively). DATA CONCLUSION The IVIM parameters, especially the renal cortex D* value, might serve as novel indicators in the differential diagnosis between DN and NDRD in patients with T2DM. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Shao-Peng Zhou
- Medical School of Chinese PLA, Beijing, China
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qian Wang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Pu Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Xue Zhai
- Medical School of Chinese PLA, Beijing, China
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jian Zhao
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xu Bai
- Medical School of Chinese PLA, Beijing, China
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lin Li
- Hospital Management Institute, Department of Innovative Medical Research, Chinese PLA General Hospital, Beijing, China
| | - Hui-Ping Guo
- Medical School of Chinese PLA, Beijing, China
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xue-Yi Ning
- Medical School of Chinese PLA, Beijing, China
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Jing Zhang
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hui-Yi Ye
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhe-Yi Dong
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Xiang-Mei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Hai-Yi Wang
- Department of Radiology, First Medical Center of Chinese PLA General Hospital, Beijing, China
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Qin J, Xie S, Yu Y, Yang J, Zhao Y, Qiu C, Li X, Zhang C, Hu Z, Tong D, Zhu J, Kuehn B, Shen W. Evaluation of Kidney Injury Using Arterial Spin Labeling and Blood Oxygen Level-Dependent MRI: An Experimental Study in Rats With Carbon Tetrachloride-Induced Liver Cirrhosis. J Magn Reson Imaging 2024. [PMID: 38299767 DOI: 10.1002/jmri.29265] [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: 11/27/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Serum creatinine (Scr) may be not suited to timely and accurately reflect kidney injury related to chronic liver disease. Currently, the ability of arterial spin labeling (ASL) and blood oxygen level-dependent (BOLD) sequences to evaluate renal blood flow (RBF) and blood oxygen in chronic liver disease remains to be verified. PURPOSE To investigate the value of ASL and BOLD imaging in evaluating hemodynamics and oxygenation changes during kidney injury in an animal model of chronic liver disease. STUDY TYPE Prospective. ANIMAL MODEL Chronic liver disease model was established by subcutaneous injection of carbon tetrachloride. Forty-three male Sprague-Dawley rats (8 weeks) were divided into a pathological group (0, 2, 4, 6, 8, 12 weeks, each group: N = 6) and a continuous-scanning group (N = 7). FIELD STRENGTH/SEQUENCE 3-T, ASL, BOLD, and T2W. ASSESSMENT Regions of interest in the cortex (CO), outer stripe of the outer medulla (OSOM), and inner stripe of the outer medulla (ISOM) are manually delineated. The RBF and T2* values at each time point (0, 2, 4, 6, 8, 12 weeks) are measured and compared. Hematoxylin-eosin score (HE Score, damage area scoring method), alpha-smooth muscle actin (α-SMA), hypoxia-inducible factor-1alpha (HIF-1α), peritubular capillar (PTC) density, Scr, and neutrophil gelatinase-associated lipocalin were harvested. STATISTICAL TESTS Analysis of variance, Spearman correlation analysis, Kruskal-Wallis tests, and receiver operating characteristic analysis with the area under the curve (AUC). A P-value <0.05 was considered statistically significant. RESULTS Renal RBF and T2* values of CO, OSOM, and ISOM were significantly different from baseline. Both RBF and T2* were significantly correlated with HE Score, α-SMA, HIF-1α, and PTC density (|r| = 0.406-0.853). RBF demonstrated superior diagnostic capability in identifying severe kidney injury in this model of chronic liver disease (AUC = 0.964). DATA CONCLUSION Imaging by ASL and BOLD may detect renal hemodynamics and oxygenation changes related to chronic liver disease early. EVIDENCE LEVEL 5 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Jiaming Qin
- The School of Medicine, Nankai University, Tianjin, China
| | - Shuangshuang Xie
- Department of Radiology, Tianjin First Central Hospital, Tianjin Institute of Imaging Medicine, Tianjin, China
| | - Yongquan Yu
- Department of Radiology, Weihai Central Hospital, Weihai, Shandong, China
| | - Jiaqi Yang
- First Central Clinical College, Tianjin Medical University, Tianjin, China
| | - Yumeng Zhao
- The School of Medicine, Nankai University, Tianjin, China
| | - Caixin Qiu
- Department of Radiology, Tianjin First Central Hospital, Tianjin Institute of Imaging Medicine, Tianjin, China
| | - Xiaotian Li
- The School of Medicine, Nankai University, Tianjin, China
| | - Cheng Zhang
- First Central Clinical College, Tianjin Medical University, Tianjin, China
| | - Zhandong Hu
- Department of Pathology, Tianjin First Central Hospital, Tianjin, China
| | - Dan Tong
- Department of Pathology, Tianjin First Central Hospital, Tianjin, China
| | - Jinxia Zhu
- MR Collaboration, Siemens Healthineers, Beijing, China
| | - Bernd Kuehn
- MR Application Predevelopment, Siemens Healthcare GmbH, Erlangen, Germany
| | - Wen Shen
- Department of Radiology, Tianjin First Central Hospital, Tianjin Institute of Imaging Medicine, Tianjin, China
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Cheng ZY, Gong SA, Chen PK, Yu ZC, Qiu C, Lin JX, Mo JB, Qian L, Feng YZ, Cai XR. Using intravoxel incoherent motion imaging to evaluate uric acid-induced renal injury and efficacy after treatment. Br J Radiol 2024; 97:274-282. [PMID: 38263841 PMCID: PMC11027338 DOI: 10.1093/bjr/tqad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/23/2023] [Accepted: 11/20/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES To validate the feasibility of intravoxel incoherent motion imaging (IVIM) for monitoring renal injury and uric acid-lowering efficacy in a rat model of hyperuricaemia. METHODS A total of 92 rats were analysed and categorized into 4 groups: control (CON), hyperuricaemia (HUA), allopurinol intervention (ALL), and combined intervention (COM). Eight rats were randomly selected from each group and underwent IVIM scanning on days 0, 1, 3, 5, 7, and 9. Quantitative magnetic resonance values (D, D*, and f values) measured from the different renal anatomical regions. Quantitative histopathological analysis was performed to assess renal tubular injury using neutrophil gelatinase-associated lipocalin (NGAL), and renal fibrosis using alpha-smooth-muscle-actin (α-SMA). Pearson's correlation analysis was used to determine the correlation between IVIM-derived parameters and the expression of NGAL and α-SMA. RESULTS The D values of the HUA, ALL, and COM groups generally showed a downward trend over time, and this fluctuation was most significant in the HUA group. The D values showed significant intergroup differences at each point, whereas only a few discrepancies were found in the D* and f values. In addition, the renal D value was negatively correlated with the positive staining rates for NGAL and α-SMA (P < .05), except for the lack of correlation between Dos and α-SMA (P > .05). CONCLUSION IVIM could be a noninvasive and potential assessment modality for the evaluation of renal injury induced by hyperuricaemia and its prognostic efficacy. ADVANCES IN KNOWLEDGE IVIM could be a surrogate manner in monitoring renal damage induced by hyperuricaemia and its treatment evaluation.
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Affiliation(s)
- Zhong-Yuan Cheng
- Medical Imaging Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Shang-Ao Gong
- Medical Imaging Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Ping-Kang Chen
- Medical Imaging Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Zong-Chao Yu
- Nephrology Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Chen Qiu
- New Medicine Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Ji-Xin Lin
- Traditional Chinese Medicine Department, Lecong Hospital of Shunde, Foshan 528315, China
| | - Jia-Bin Mo
- Department of Radiology, The Affiliated Shunde Hospital of Jinan University, Foshan, Guangdong Province 528306, China
| | - Long Qian
- Department of Biomedical Engineering, College of Engineering, Peking University, Beijing 100091, China
| | - You-Zhen Feng
- Medical Imaging Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
| | - Xiang-Ran Cai
- Medical Imaging Department, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
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Zhao D, Wang W, Niu YY, Ren XH, Shen AJ, Xiang YS, Xie HY, Wu LH, Yu C, Zhang YY. Amide Proton Transfer-Weighted Magnetic Resonance Imaging for Application in Renal Fibrosis: A Radiological-Pathological-Based Analysis. Am J Nephrol 2024; 55:334-344. [PMID: 38228096 DOI: 10.1159/000536232] [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: 08/19/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Renal fibrosis (RF), being the most important pathological change in the progression of CKD, is currently assessed by the evaluation of a biopsy. This present study aimed to apply a novel functional MRI (fMRI) protocol named amide proton transfer (APT) weighting to evaluate RF noninvasively. METHODS Male Sprague-Dawley (SD) rats were initially subjected to bilateral kidney ischemia/reperfusion injury (IRI), unilateral ureteral obstruction, and sham operation, respectively. All rats underwent APT mapping on the 7th and 14th days after operation. Besides, 26 patients underwent renal biopsy at the Nephrology Department of Shanghai Tongji Hospital between July 2022 and May 2023. Patients underwent APT and apparent diffusion coefficient (ADC) mappings within 1 week before biopsy. MRI results of both patients and rats were calculated by comparing with gold standard histology for fibrosis assessment. RESULTS In animal models, the cortical APT (cAPT) and medullary APT (mAPT) values were positively correlated with the degree of RF. Compared to the sham group, IRI group showed significantly increased cAPT and mAPT values on the 7th and 14th days after surgery, but no group differences were found in ADC values. Similar results were found in human patients. Cortical/medullary APT values were significantly increased in patients with moderate-to-severe fibrosis than in patients with mild fibrosis. ROC curve analysis indicated that APT value displayed a better diagnostic value for RF. Furthermore, combination of cADC and cAPT improved fibrosis detection by imaging variables alone (p < 0.1). CONCLUSION APT values had better diagnostic capability at early stage of RF compared to ADC values, and the addition of APT imaging to conventional ADC will significantly improve the diagnostic performance for predicting kidney fibrosis.
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Affiliation(s)
- Dan Zhao
- Department of Nephrology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China,
| | - Wei Wang
- Department of Radiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yang-Yang Niu
- Department of Nephrology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xi-Hui Ren
- Department of Radiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ai-Jun Shen
- Department of Radiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yong-Sheng Xiang
- Department of Radiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong-Yan Xie
- Department of Nephrology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Le-Hao Wu
- Department of Nephrology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chen Yu
- Department of Nephrology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying-Ying Zhang
- Department of Nephrology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Klinkhammer BM, Boor P. Kidney fibrosis: Emerging diagnostic and therapeutic strategies. Mol Aspects Med 2023; 93:101206. [PMID: 37541106 DOI: 10.1016/j.mam.2023.101206] [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: 04/28/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023]
Abstract
An increasing number of patients worldwide suffers from chronic kidney disease (CKD). CKD is accompanied by kidney fibrosis, which affects all compartments of the kidney, i.e., the glomeruli, tubulointerstitium, and vasculature. Fibrosis is the best predictor of progression of kidney diseases. Currently, there is no specific anti-fibrotic therapy for kidney patients and invasive renal biopsy remains the only option for specific detection and quantification of kidney fibrosis. Here we review emerging diagnostic approaches and potential therapeutic options for fibrosis. We discuss how translational research could help to establish fibrosis-specific endpoints for clinical trials, leading to improved patient stratification and potentially companion diagnostics, and facilitating and optimizing development of novel anti-fibrotic therapies for kidney patients.
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Affiliation(s)
| | - Peter Boor
- Institute of Pathology, RWTH Aachen University Hospital, Aachen, Germany; Electron Microscopy Facility, RWTH Aachen University Hospital, Aachen, Germany; Division of Nephrology and Immunology, RWTH Aachen University Hospital, Aachen, Germany.
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Girometti R, Bertolotto M. Editorial for "Noninvasive Assessment of the Renal Function, Oxford Classification and Prognostic Risk Stratification of IgAN by Using Intravoxel Incoherent Motion Diffusion-Weighted Imaging and Blood Oxygenation Level-Dependent MRI". J Magn Reson Imaging 2023; 58:892-893. [PMID: 36651295 DOI: 10.1002/jmri.28598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/19/2023] Open
Affiliation(s)
- Rossano Girometti
- Institute of Radiology, Department of Medicine (DAME), University of Udine, University Hospital S. Maria della Misericordia-Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Michele Bertolotto
- Radiology Unit, Department of Medical, Surgical and Health Sciences, University of Trieste, University Hospital Cattinara-Azienda Sanitaria Universitaria Giuliano Isontina (ASU GI), Trieste, Italy
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