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Hirai T, Mori Y, Ogura T, Kondo Y, Sakazaki Y, Ishitsuka Y, Sudo A, Iwamoto T. Influence of loop diuretics on denosumab-induced hypocalcaemia in osteoporosis: a retrospective observational analysis. J Pharm Health Care Sci 2024; 10:60. [PMID: 39334301 PMCID: PMC11437979 DOI: 10.1186/s40780-024-00380-8] [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: 06/25/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND We examined whether denosumab-induced hypocalcaemia is evident in osteoporosis when given loop diuretics that promote urinary calcium excretion. METHODS Japanese Spontaneous Adverse Drug Event Reports was analyzed to examine signals for denosumab-induced hypocalcaemia co-administered loop diuretics. We retrospectively included osteoporotic patients to detect predictors for denosumab-induced hypocalcaemia (corrected calcium level < 8.5 mg/dL) using multivariate logistic regression analysis. We compared differences in corrected calcium levels (ΔCa = nadir-baseline). RESULTS A significant signal for hypocalcaemia was detected (Reporting odds ratio = 865.8, 95% confidence interval [95% CI]: 596.8 to 1255.9, p < 0.0001). Among 164 patients (hypocalcaemia, 12%), loop diuretics have a significant association with hypocalcaemia (odds ratio [OR] = 6.410, 95% CI: 1.005 to 40.90, p = 0.0494). However, hypocalcaemia was found to be lower in high corrected calcium levels at baseline (OR = 0.032, 95% CI: 0.005 to 0.209, p < 0.0001) and calcium and vitamin D supplementation (OR = 0.285, 95% CI: 0.094 to 0.868, p = 0.0270). In the non-hypocalcaemia, ΔCa decreased significantly in the denosumab plus loop diuretics than in the denosumab alone (-0.9 [-1.3 to -0.7] mg/dL vs. -0.5 [-0.8 to -0.3] mg/dL, p = 0.0156). However, ΔCa remained comparable in the hypocalcaemia despite loop diuretics co-administration (-1.0 [-1.2 to -0.8] mg/dL vs. -0.8 [-1.5 to -0.7] mg/dL, p = 0.7904). CONCLUSIONS Loop diuretics may predispose to developing denosumab-induced hypocalcaemia.
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Affiliation(s)
- Toshinori Hirai
- Department of Pharmacy, Faculty of Medicine, Mie University Hospital, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
- Department of Pharmacy, Tokyo Medical and Dental University Hospital, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yukari Mori
- Department of Pharmacy, Faculty of Medicine, Mie University Hospital, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oehonmachi, Chuo-ku, Kumamoto, Kumamoto, 862-0973, Japan
| | - Yuka Sakazaki
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oehonmachi, Chuo-ku, Kumamoto, Kumamoto, 862-0973, Japan
| | - Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oehonmachi, Chuo-ku, Kumamoto, Kumamoto, 862-0973, Japan
| | - Akihiro Sudo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oehonmachi, Chuo-ku, Kumamoto, Kumamoto, 862-0973, Japan
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Faculty of Medicine, Mie University Hospital, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
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Vachey C, Candellier A, Toutain S, Mac-Way F. The Bone-Vascular Axis in Chronic Kidney Disease: From Pathophysiology to Treatment. Curr Osteoporos Rep 2024; 22:69-79. [PMID: 38195897 DOI: 10.1007/s11914-023-00858-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE OF REVIEW This review aims to describe the pathogenic factors involved in bone-vessel anomalies in CKD which are the object of numerous experimental and clinical research. RECENT FINDINGS Knowledge on the pathophysiological mechanisms involved in the regulation of vascular calcification and mineral-bone disorders is evolving. Specific bone turnover anomalies influence the vascular health while recent studies demonstrate that factors released by the calcified vessels also contribute to bone deterioration in CKD. Current therapies used to control mineral dysregulations will impact both the vessels and bone metabolism. Available anti-osteoporotic treatments used in non-CKD population may negatively or positively affect vascular health in the context of CKD. It is essential to study the bone effects of the new therapeutic options that are currently under investigation to reduce vascular calcification. Our paper highlights the complexity of the bone-vascular axis and discusses how current therapies may affect both organs in CKD.
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Affiliation(s)
- Clément Vachey
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada
| | - Alexandre Candellier
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada
| | - Soline Toutain
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada.
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Spångeus A, Rydetun J, Woisetschläger M. Prevalence of denosumab-induced hypocalcemia: a retrospective observational study of patients routinely monitored with ionized calcium post-injection. Osteoporos Int 2024; 35:173-180. [PMID: 37750930 PMCID: PMC10786736 DOI: 10.1007/s00198-023-06926-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
We assessed the prevalence of hypocalcemia after denosumab injections in a real-world cohort routinely monitored for calcium during up to 7.5 years of treatment. Among 1096 injections in 242 patients, 6.3% resulted in hypocalcemia, and was independent of the injection number. Severe hypocalcemia was rare (1%). PURPOSE To assess the prevalence of and risk factors for hypocalcemia after administration of denosumab in a patient cohort routinely monitored for ionized calcium after each dose. METHODS In this retrospective observational study, we analyzed denosumab-induced hypocalcemia in a real-world cohort who were routinely followed up with ionized calcium pre- and post-injection (within 31 days after injection) during the period 2011 to 2020. RESULTS In total, we included data from 1096 denosumab injections in 242 individuals (1-15 injections per patient). The mean age for the first injection was 74 ± 10 years, and 88% were female. Post-injection hypocalcemia occurred after 6.3% of all injections (4.6% mild, 0.6% moderate, and 1.1% severe) and was independent of the number of injections (rate of hypocalcemia varied from 3-8%). Risk factors for hypocalcemia were male sex, severe renal failure, pre-injection hypocalcemia, hypomagnesemia, hypophosphatemia, and vitamin D insufficiency. Furthermore, older age was not associated with an increased hypocalcemia risk. CONCLUSIONS Denosumab-induced hypocalcemia is a prevalent adverse event, which occurs independently of the number of injections. However, severe hypocalcemia is a rare occurrence, and severe renal failure and nutritional status appear to be important predictive factors. Magnesium and phosphate might add value in the pre-injection risk assessment; however, this observation needs to be confirmed in larger cohorts.
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Affiliation(s)
- Anna Spångeus
- Department of Acute Internal Medicine and Geriatrics, Department of Medical and Health Sciences, Linköping University Hospital, Linköping University, Building 444, Level 11, Campus US, 581 83, Linköping, Sweden.
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Johan Rydetun
- Department of Acute Internal Medicine and Geriatrics, Department of Medical and Health Sciences, Linköping University Hospital, Linköping University, Building 444, Level 11, Campus US, 581 83, Linköping, Sweden
| | - Mischa Woisetschläger
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Radiology, Linköping University Hospital, Linköping, Sweden
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Cowan A, Jeyakumar N, McArthur E, Fleet JL, Kanagalingam T, Karp I, Khan T, Muanda FT, Nash DM, Silver SA, Thain J, Weir MA, Garg AX, Clemens KK. Hypocalcemia Risk of Denosumab Across the Spectrum of Kidney Disease: A Population-Based Cohort Study. J Bone Miner Res 2023; 38:650-658. [PMID: 36970786 DOI: 10.1002/jbmr.4804] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/28/2023] [Accepted: 03/21/2023] [Indexed: 04/11/2023]
Abstract
Denosumab can be used in patients with chronic kidney disease (CKD) but has been linked with cases of severe hypocalcemia. The incidence of and risk factors for hypocalcemia after denosumab use are not well established. Using linked health care databases at ICES, we conducted a population-based cohort study of adults >65 years old with a new prescription for denosumab or a bisphosphonate between 2012 and 2020. We assessed incidence of hypocalcemia within 180 days of drug dispensing and stratified results by estimated glomerular filtration rate (eGFR in mL/min/1.73 m2 ). We used Cox proportional hazards to assess risk factors for hypocalcemia. There were 59,151 and 56,847 new denosumab and oral bisphosphonate users, respectively. Of the denosumab users, 29% had serum calcium measured in the year before their prescription, and one-third had their serum calcium checked within 180 days after their prescription. Mild hypocalcemia (albumin corrected calcium <2.00 mmol/L) occurred in 0.6% (95% confidence interval [CI] 0.6, 0.7) of new denosumab users and severe hypocalcemia (<1.8 mmol/L) in 0.2% (95% CI 0.2, 0.3). In those with an eGFR <15 or receiving maintenance dialysis, the incidence of mild and severe hypocalcemia was 24.1% (95% CI 18.1, 30.7) and 14.9% (95% CI 10.1, 20.7), respectively. In this group, kidney function and baseline serum calcium were strong predictors of hypocalcemia. We did not have information on over-the-counter vitamin D or calcium supplementation. In new bisphosphonate users, the incidence of mild hypocalcemia was 0.3% (95% CI 0.3, 0.3) with an incidence of 4.7% (95% CI 1.5, 10.8) in those with an eGFR <15 or receiving maintenance dialysis. In this large population-based cohort, we found that the overall risk of hypocalcemia with new denosumab use was low but increased substantially in those with eGFR <15 mL/min/1.73 m2 . Future studies should investigate strategies to mitigate hypocalcemia. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Andrea Cowan
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
| | - Nivethika Jeyakumar
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Eric McArthur
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Jamie L Fleet
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Igor Karp
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Tayyab Khan
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Danielle M Nash
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | | | - Jenny Thain
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | - Matthew A Weir
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Amit X Garg
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Kristin K Clemens
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
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Boots JMM, Quax RAM. High-Dose Intravenous Iron with Either Ferric Carboxymaltose or Ferric Derisomaltose: A Benefit-Risk Assessment. Drug Saf 2022; 45:1019-1036. [PMID: 36068430 PMCID: PMC9492608 DOI: 10.1007/s40264-022-01216-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/22/2022]
Abstract
The intravenous iron formulations ferric carboxymaltose (FCM) and ferric derisomaltose (FDI) offer the possibility of administering a large amount of iron in one infusion. This results in faster correction of anemia and the formulations being better tolerated than oral iron formulations. This triad of logistic advantages, improved patient convenience, and fast correction of anemia explains the fact that intravenous iron formulations nowadays are frequently prescribed worldwide in the treatment of iron deficiency anemia. However, these formulations may result in hypophosphatemia by inducing a strong increase in active fibroblast growth factor-23 (FGF-23), a hormone that stimulates renal phosphate excretion. This effect is much more pronounced with FCM than with FDI, and therefore the risk of developing hypophosphatemia is remarkably higher with FCM than with FDI. Repeated use of FCM may result in severe osteomalacia, which is characterized by bone pain, Looser zones (pseudofractures), and low-trauma fractures. Intravenous iron preparations are also associated with other adverse effects, of which hypersensitivity reactions are the most important and are usually the result of a non-allergic complement activation on nanoparticles of free labile iron-Complement Activation-Related Pseudo-Allergy (CARPA). The risk on these hypersensitivity reactions can be reduced by choosing a slow infusion rate. Severe hypersensitivity reactions were reported in < 1% of prospective trials and the incidence seems comparable between the two formulations. A practical guideline has been developed based on baseline serum phosphate concentrations and predisposing risk factors, derived from published cases and risk factor analyses from trials, in order to establish the safe use of these formulations.
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Affiliation(s)
- Johannes M M Boots
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
| | - Rogier A M Quax
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
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Rhee Y, Chang DG, Ha J, Kim S, Lee Y, Jo E, Koh JM. Real-World Safety and Effectiveness of Denosumab in Patients with Osteoporosis: A Prospective, Observational Study in South Korea. Endocrinol Metab (Seoul) 2022; 37:497-505. [PMID: 35654577 PMCID: PMC9262695 DOI: 10.3803/enm.2022.1427] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/04/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGRUOUND The efficacy and safety of denosumab have been established in a phase 3, randomized, placebo-controlled trial in Korean postmenopausal women with osteoporosis. This postmarketing surveillance study was aimed to investigate the safety and effectiveness of denosumab in Korean real-world clinical practice. METHODS Patients with osteoporosis who had received denosumab per the Korean approved indications in the postmarketing setting between September 2014 and September 2019 were enrolled. The primary endpoint was the incidence of adverse events (AEs) and adverse drug reactions (ADRs). The secondary endpoint was the percent change from baseline in bone mineral density (BMD) of the lumbar spine, total hip, and femoral neck. RESULTS Of the 3,221 patients enrolled, 3,185 were included in the safety analysis set; 2,973 (93.3%) were female, and the mean± standard deviation (SD) age was 68.9±9.9 years. The mean±SD study period was 350.0±71.4 days. AEs, fatal AEs, and ADRs occurred in 19.3%, 0.8%, and 1.6%, respectively. The most frequent AEs, occurring in >0.5% of patients, were dizziness (0.7%), arthralgia (0.7%), back pain (0.6%), and myalgia (0.6%). Hypocalcemia occurred in 0.3% of patients. There were no cases of osteonecrosis of the jaw and atypical femoral fracture. Mean±SD percent change from baseline in BMD of the lumbar spine, total hip, and femoral neck was 7.3%±23.6%, 3.6%±31.4%, and 3.2%±10.7%, respectively. CONCLUSION The safety and effectiveness of denosumab in Korean patients with osteoporosis in this study were comparable with those in the Korean randomized controlled trial, with no new safety findings.
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Affiliation(s)
- Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | | | - Euna Jo
- Amgen Korea Ltd., Seoul, Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gopaul A, Kanagalingam T, Thain J, Khan T, Cowan A, Sultan N, Clemens KK. Denosumab in chronic kidney disease: a narrative review of treatment efficacy and safety. Arch Osteoporos 2021; 16:116. [PMID: 34319515 DOI: 10.1007/s11657-021-00971-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/04/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED People with chronic kidney disease (CKD) are at high risk of bone fractures. In this review, we summarize the complexity of fracture prevention in CKD, describe the usefulness of a medication called denosumab, and review its safety in this population. Our article will help doctors manage brittle bones in CKD and encourage researchers to conduct more studies to improve bone health in CKD. PURPOSE Patients with CKD are at increased risk of fragility fractures and associated consequences. We discuss the complexity of fracture prevention in CKD, summarize the efficacy and safety of denosumab, and provide an approach to denosumab-induced hypocalcemia. METHODS Using predefined terms, we searched PubMed, MEDLINE, and Google Scholar for studies on fracture prevention in CKD and the efficacy and safety of denosumab. We included observational studies, randomized controlled trials (RCTs), meta-analyses, evidence-based reviews, and clinical practice guidelines. RESULTS The diagnosis of osteoporosis and prevention of related fragility fractures is complex in CKD, particularly in those with advanced and end-staged kidney disease (ESKD). Prior to initiating denosumab, it is important to assess for and optimize CKD-mineral and bone disorders (CKD-MBD). In observational studies and small RCTs, denosumab has been shown to improve bone mineral density and reduce bone turnover in CKD, but there have been no studies focused upon its fracture efficacy. Denosumab-induced hypocalcemia has also been reported, which disproportionately impacts those with ESKD. Risk factors for hypocalcemia with denosumab use in CKD include lower baseline serum calcium and 25 hydroxyvitamin D and both low and high bone turnover. Choosing the "right patient" for denosumab, supplementing with calcium and vitamin D, adjusting calcium dialysate, and close clinical monitoring are essential if considering this drug. CONCLUSION With optimization of CKD-MBD, calcium and vitamin D supplementation, and close monitoring, denosumab can be considered in CKD. There are however opportunities to better understand its fracture efficacy and safety in an RCT setting.
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Affiliation(s)
- Aquila Gopaul
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tharsan Kanagalingam
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jenny Thain
- Division of Geriatrics, Western University, London, ON, Canada
| | - Tayyab Khan
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada.,St. Joseph's Health Care London, London, ON, Canada
| | - Andrea Cowan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Nabil Sultan
- Division of Nephrology, Western University, London, ON, Canada.,London Health Sciences Centre, London, ON, Canada
| | - Kristin K Clemens
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada. .,St. Joseph's Health Care London, London, ON, Canada. .,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada. .,ICES, Ontario, Canada.
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