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Tay TKC, Rehena G, Zhuang KD, Irani FG, Gogna A, Too CW, Chong TT, Tan BS, Tan CS, Tay KH. Comparison of pharmacological thrombolysis with mechanical thrombectomy in thrombosed arteriovenous fistulas and grafts: a systemic review and meta-analysis. Clin Radiol 2024; 79:e624-e633. [PMID: 38320944 DOI: 10.1016/j.crad.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/09/2023] [Accepted: 12/12/2023] [Indexed: 02/08/2024]
Abstract
AIM To compare the effectiveness and safety of pharmacological thrombolysis and mechanical thrombectomy. MATERIAL AND METHODS This review was conducted in accordance with the PRISMA guidelines. Pooled proportions and subgroup analysis were calculated for primary and secondary patency rates, technical success, clinical success, major and minor complications rates. RESULTS This systematic review identified a total of 6,492 studies of which 17 studies were included for analysis. A total of 1,089 patients comprising 451 (41.4 %) and 638 (58.6 %) patients who underwent thrombolysis and mechanical thrombectomy procedures, respectively, were analysed. No significant differences were observed between thrombolysis and mechanical thrombectomy procedures in terms of technical success, clinical success, major and minor complications rates, primary and secondary patency rates; however, subgroup analysis of overall arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) demonstrated a significantly higher rate of major complications within the AVF group (p=0.0248). CONCLUSION The present meta-analysis suggests that pharmacological thrombolysis and mechanical thrombectomy procedures are similarly effective and safe; however, AVFs are subject to higher major complications compared to AVGs.
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Affiliation(s)
| | - G Rehena
- Duke-NUS Medical School, Singapore
| | - K D Zhuang
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - F G Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - A Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - C W Too
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - T T Chong
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - B S Tan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - C S Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - K H Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore.
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Maleux G. Management of Thrombosed Dialysis Access Circuits. Cardiovasc Intervent Radiol 2023; 46:1162-1167. [PMID: 37055545 DOI: 10.1007/s00270-023-03434-w] [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] [Received: 12/16/2022] [Accepted: 03/27/2023] [Indexed: 04/15/2023]
Abstract
Thrombotic occlusion of autologous arteriovenous fistulas or synthetic arteriovenous grafts is a serious adverse event in hemodialysis patients and declotting should be performed before next hemodialysis session, in order to avoid a central venous catheter. Various techniques exist to declot a thrombosed vascular access, including open surgical thrombectomy, catheter-directed thrombolysis and use of different types of percutaneous thrombo-aspiration catheters and mechanical thrombectomy devices. These devices can be categorized as devices with direct wall contact and hydrodynamic devices without direct wall contact. Technical and early clinical outcome results of percutaneous hemodialysis declotting are high and ranging between 70 and 100%; late clinical patency results are much lower related to restenosis or re-thrombosis; these patency results are higher for autologous arteriovenous fistulas compared to synthetic arteriovenous grafts and mainly depend on the combined efficacy of successful thrombectomy and durable treatment of the underlying stenoses, associated with the acute thrombosis.
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Affiliation(s)
- Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.
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Kramer A, Ross J, Gasparis AP. Chameleon™ PTA balloon catheter: A single device in managing thrombosed AV access. J Vasc Access 2023; 24:305-310. [PMID: 34159836 DOI: 10.1177/11297298211027477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thrombectomy is a common procedure for maintenance of arteriovenous (AV) access and is critical to prolong access life. Techniques for performing thrombectomy are incredibly diverse, ranging from open surgical procedures to percutaneous interventions. Percutaneous interventions include a combination of thrombectomy devices to clear the thrombus and balloon angioplasty to treat the underlying lesion. In this case report we describe a novel technique using a single device, the Chameleon™ PTA balloon catheter (Medtronic, Minneapolis, MN) balloon catheter, to safely and efficiently perform a percutaneous intervention.
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Affiliation(s)
- Ari Kramer
- Medical Group of the Carolinas-Vascular Access Services, Spartanburg, SC, USA
| | - John Ross
- Reginal Medical Center, Orangeburg, SC, USA
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Deogaonkar G, Thulasidasan N, Phulambrikar R, Diamantopoulos A, Sran K, Ahmed I, Loukopoulos I, Karunanithy N. Endovascular salvage of thrombosed haemodialysis vascular access. VASA 2023; 52:63-70. [PMID: 36464999 DOI: 10.1024/0301-1526/a001043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Haemodialysis access thrombosis is associated with significant morbidity and access abandonment rates, for which endovascular salvage is a well described treatment option. This study aimed to evaluate the outcomes of endovascular salvage procedures of thrombosed vascular access circuits and identify factors influencing outcomes. Patients and methods: Retrospective review of 328 consecutive procedures performed over 10 years at our institution between January 2010 and December 2019. Patient demographics, access circuit characteristics, procedure details and outcome data were collected. Kaplan-Meier survival curves were used to estimate patency rates and Cox multivariate regression analysis to identify factors affecting outcomes. Results: Technical and clinical success rates were 87.8% and 75.9% respectively. The primary, primary assisted and secondary patency rates at 6 months were 42.2%, 46.7% and 59.1%; and at 12 months were 23.4%, 28.3% and 41.8% respectively. Median access circuit survival was 9.2 months. Major complication rate was 5.2% including 3 procedure-related deaths. Native AVF, lower time from thrombosis to intervention and pharmacomechanical thrombectomy using AngioJetTM predicted positive outcomes. Previous thrombectomy within 3 months and residual thrombus at completion were associated with poorer outcomes. Age and hypertension predicted higher complication rates. Conclusions: This is one of the largest single center series of endovascular salvage of thrombosed haemodialysis access and demonstrates that endovascular treatment is effective and provides durable access circuit survival. Careful patient screening is essential to optimize outcomes.
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Affiliation(s)
- Ganesh Deogaonkar
- Department of Interventional Radiology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Narayanan Thulasidasan
- Department of Interventional Radiology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Rutuja Phulambrikar
- Department of Interventional Radiology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | | | - Kiran Sran
- Department of Nephrology & Transplantation, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Irfan Ahmed
- Department of Interventional Radiology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ioannis Loukopoulos
- Department of Nephrology & Transplantation, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Narayan Karunanithy
- Department of Interventional Radiology, Guy's & St Thomas' NHS Foundation Trust, London, UK.,School of Biomedical Engineering & Imaging Sciences, King's College London, UK
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Ates OF, Taydas O. Modified lyse and wait technique for the treatment of dialysis fistula thrombosis: Percutaneous thrombolytic therapy with a 27-G dental needle. Semin Dial 2021; 35:522-527. [PMID: 34963036 DOI: 10.1111/sdi.13047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The lyse and wait technique is a percutaneous endovascular technique in the treatment of thrombosed dialysis fistulas. In this study, our aim was to introduce a more easily applicable modification of the lyse and wait technique and present our results. METHODS A total of 84 patients (56 male; 66.6%), with a mean age of 61 years, were included in the study. The treatment was performed in patients presenting with dialysis fistula thrombosis no more than 1 week before the procedure, whose thrombosed segment length was less than 10 cm. A 27-G dental needle was inserted into the thrombosed segment under ultrasonography guidance, and 5 mg of alteplase was injected in a controlled manner. After about 6 to 12 h, the patients were taken to the angiography unit, and balloon angioplasty was performed. RESULTS The technical and clinical success of the procedure was 98.8%. Technical and clinical failure occurred in only one patient. The median primary patency duration was 13.5 months. None of the patients had major complications. At the end of 12 months, the primary patency rate was 66.6%, and the secondary patency rate was 80%. CONCLUSIONS Our technique has shown to have high technical and clinical success and patency.
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Affiliation(s)
- Omer Faruk Ates
- School of Medicine, Department of Radiology, Sakarya University, Sakarya, Turkey
| | - Onur Taydas
- School of Medicine, Department of Radiology, Sakarya University, Sakarya, Turkey
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Kitrou PM, Katsanos K, Papadimatos P, Theofanis M, Christeas N, Lampropoulos G, Karnabatidis D. Use of the Covera Stent Graft for the Treatment of Dysfunctional or Thrombosed Arteriovenous Grafts: A Retrospective Analysis of 64 Patients. J Vasc Interv Radiol 2020; 31:630-634. [PMID: 32127320 DOI: 10.1016/j.jvir.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To retrospectively evaluate the safety and effectiveness of the Covera stent graft (SG) for the treatment of dysfunctional or thrombosed arteriovenous grafts (AVGs). MATERIALS AND METHODS Within 29 months (February 2016-August 2018), 79 patients underwent Covera SG placement in the authors' department for the treatment of dysfunctional AVGs. Data were available for 64 patients who underwent 64 procedures, using 64 devices. Minimum follow-up was 6 months, unless reintervention occurred. Mean follow-up was 277 days (6-923 days). Treatment characteristics were 51 cases with venous-graft anastomosis (VGA) stenosis (79.7%), 13 cases of puncture zone stenosis (20.3%), 14 cases of in SG stenosis (21.9%), 8 cases of pseudoaneurysm treatment (12.5%) (1 treatment area might have had more than 1 characteristic). Thirty-six patients presented with thrombosis (56.2%), and 31 of 64 case were de novo treatment areas (48.4%). Primary outcome measurements were technical success and post-intervention primary patency (PIPP) at 6 months, whereas secondary outcome measurements included factors influencing primary outcome. RESULTS Technical success was 100%. Median PIPP was 336 days, and 73.6% of treatment areas were patent at 6 months. There were no significant differences in terms of PIPP when de novo treatment areas were compared with restenotic areas (519 vs. 320 days, respectively; P = .1); patients who presented with versus those who presented without thrombosis (320 vs. 583 days, respectively; P = .07); puncture zone stenosis or elsewhere (329 vs. 686 days, respectively; P = .52); and VGA stenosis or elsewhere (336 vs. 335 days, respectively; P = .9). CONCLUSIONS Use of the Covera SG for AVG treatment was safe and effective in every type of treatment area presented in this retrospective analysis.
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Affiliation(s)
- Panagiotis M Kitrou
- Interventional Radiology Department, Patras University Hospital, Patras 26500, Greece.
| | - Konstantinos Katsanos
- Interventional Radiology Department, Patras University Hospital, Patras 26500, Greece
| | | | - Michail Theofanis
- Interventional Radiology Department, Patras University Hospital, Patras 26500, Greece
| | - Nicolaos Christeas
- Interventional Radiology Department, Patras University Hospital, Patras 26500, Greece
| | - George Lampropoulos
- Vascular Surgery Department, Patras University Hospital, Patras 26500, Greece
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Yilmazsoy Y, Ozyer U. Long-term results of endovascular treatment for arteriovenous dialysis access thrombosis in 143 patients: A single center experience. J Vasc Access 2019; 20:545-552. [DOI: 10.1177/1129729819865808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective:This study aimed to determine the long-term patency duration and rate of thrombosis of autologous arteriovenous fistulas and synthetic grafts treated with endovascular methods in a large patient population.Methods:A total of 144 arteriovenous accesses (37 radiocephalic, 51 brachiobasilic, 41 brachiocephalic, and 15 femorofemoral) from 143 patients were included in the study. A total of 304 endovascular thrombolytic treatment procedures were performed for 94 (65%) arteriovenous fistula and 50 (35%) arteriovenous graft accesses.Results:The procedural technical success rate was 98.7%. The mean follow-up duration was 32.5 (range, 3–132) months. The primary patency rates for arteriovenous fistulas and arteriovenous grafts were 78% and 78% at 6 months, 66% and 63% at 1 year, and 45% and 0% at 36 months, respectively. The assisted primary patency rates for arteriovenous fistulas and arteriovenous grafts were 82% and 84% at 6 months, 71% and 69% at 1 year, 51% and 29% at 36 months, and 30% and 1% at 60 months, respectively. The secondary patency rates for arteriovenous fistulas and arteriovenous grafts were 94% and 93% at 6 months, 85% and 85% at 1 year, 58% and 59% at 36 months, and 47% and 48% at 60 months, respectively.Conclusion:Although the primary patency durations for arteriovenous fistulas were better after endovascular thrombolytic treatment than those for arteriovenous grafts, the long-term outcomes of assisted primary and secondary patency durations after repeated procedures were similar for both types of arteriovenous accesses.
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Affiliation(s)
| | - Umut Ozyer
- Department of Radiology, Faculty of Medicine, Baskent University, Ankara, Turkey
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Tan RY, Pang SC, Teh SP, Lee KG, Chong TT, Gogna A, Tan CS. Comparison of alteplase and urokinase for pharmacomechanical thrombolysis of clotted hemodialysis access. J Vasc Access 2018; 20:501-506. [PMID: 30585114 DOI: 10.1177/1129729818819735] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Percutaneous pharmacomechanical thrombolysis is increasingly used to salvage thrombosed hemodialysis access. We aim to evaluate the effectiveness of alteplase compared to urokinase in percutaneous pharmacomechanical thrombolysis clotted access. METHODS Records of patients who underwent pharmacomechanical thrombolysis at Interventional Nephrology Suite in a tertiary teaching hospital from 1 January 2016 to 31 December 2016 were reviewed. Technical and clinical success rates, thrombosis-free and cumulative survivals, procedure time, and radiation dose imparted to patients were compared for pharmacomechanical thrombolysis with urokinase versus alteplase. RESULTS A total of 122 incident patients underwent pharmacothrombolysis (n = 53 for urokinase, n = 69 for alteplase) during the study period. The mean dose of urokinase and alteplase used was 176,897 ± 73,418 units and 3.7 ± 0.8 mg, respectively. Pharmacomechnical thrombolysis using urokinase versus alteplase has similar technical success rate (98.1% vs 97.1%, p = 0.599), clinical success rate (88.7% vs 97.1%, p = 0.068), complication rate (9.4% vs 13.0%, p = 0.373), and primary patency rates at 3 months (57.1% vs 70.1%, p = 0.106). Thrombosis-free survivals of the vascular access were 113.2 (35.3, 196) days versus 122 (84, 239) days (p = 0.168). Cumulative survivals were 239 (116, 320) vs 213 (110.5, 316.5) days (p = 0.801). Procedure time, fluoroscopy time, skin dose, and dose were significantly lower for pharmacomechanical thrombolysis using alteplase compared to urokinase (p = 0.045, p < 0.0001, p = 0.006, p = 0.001, respectively). Stenting was found to be associated with successful dialysis following thrombolysis on univariate analysis (odds ratio: 9.167, 95% confidence interval: 1.391-19.846, p = 0.021), although this was no longer significant in multivariate analysis (p = 0.078). CONCLUSION Alteplase is an effective and safe alternative to urokinase for pharmacomechanical thrombolysis of clotted vascular access.
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Affiliation(s)
- Ru Yu Tan
- 1 Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Suh Chien Pang
- 1 Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Swee Ping Teh
- 1 Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Kian Guan Lee
- 1 Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- 2 Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Apoorva Gogna
- 3 Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- 1 Department of Renal Medicine, Singapore General Hospital, Singapore
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Kitrou P, Papasotiriou M, Katsanos K, Karnabatidis D, Goumenos DS, Papachristou E. Recent developments in endovascular interventions to sustain vascular access patency in haemodialysis patients. Nephrol Dial Transplant 2018; 34:1994-2001. [DOI: 10.1093/ndt/gfy354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/12/2018] [Indexed: 12/22/2022] Open
Abstract
Abstract
There is amassed evidence regarding the use of endovascular procedures for the treatment of vascular access stenosis and thrombosis. A review was conducted based on available randomized trials, cohort studies and retrospective analyses published after 2000 on endovascular treatment of dysfunctional and thrombosed vascular access, with an aim to illustrate the available device and procedural options. The use of paclitaxel-coated balloons, cutting balloons and covered stents is described in the field of vascular access stenosis. The broad spectrum of available devices and endovascular declotting procedures ranging from thrombolysis to thrombectomy is also discussed. Overall, in this review we demonstrate the increasing role of endovascular procedures in vascular access treatment and the improved patency outcomes provided by the implementation of novel endovascular devices. Moreover, the improvement of post-intervention primary patency rates after endovascular declotting procedures and the shift to more thrombectomy-dependent procedures over time is also highlighted. In conclusion, endovascular treatment of dialysis access stenosis and thrombosis has an established role, owing to the implementation of sophisticated devices, allowing, when needed, the simultaneous treatment of thrombosis and the underlying stenosis.
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Affiliation(s)
- Panagiotis Kitrou
- Interventional Radiology Department, Patras University Hospital, Patras, Greece
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Lu M, Li H, Feng J, Hu W. Ultrasound-Guided Pharmacomechanical Thrombolysis and Angioplasty for Treatment of Acute Thrombotic Prosthetic Arteriovenous Access: 5-Year Experience with 154 Procedures in a Single Center. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2314-2322. [PMID: 30115490 DOI: 10.1016/j.ultrasmedbio.2018.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/24/2018] [Accepted: 06/27/2018] [Indexed: 06/08/2023]
Abstract
Pharmacomechanical thrombolysis (PMT) and percutaneous transluminal angioplasty (PTA) for the treatment of acute thrombotic prosthetic arteriovenous access (PAVA) are conventionally guided by radiography, which may cause radiation injury and requires the use of radiographic contrast media. The aim of the present study was to summarize our experience with ultrasound-guided PMT and PTA as an alternative to radiographic guidance. Between December 2012 and October 2016, 114 patients with acute thrombosis of PAVA were treated urgently with ultrasound-guided PMT and PTA to restore blood flow. The patients were followed up every 3 mo postoperatively. The 114 included patients underwent 154 episodes of ultrasound-guided PMT and PTA and were followed up for a mean of 20.7 ± 9.1 mo. The technical success rate was 91.6%, and the clinical success rate was 97.4%. Post-intervention-assisted primary patency rates at 3, 6, 12 and 24 mo were 90.8%, 78.8%, 66.3% and 50.9%, respectively. Post-intervention secondary patency rates at 3, 6, 12 and 24 months were 96.3%, 94.5%, 90.6% and 85.4%, respectively. PMT and PTA for the treatment of PAVA were performed successfully under the guidance of ultrasound with a success rate similar to that under radiographic guidance, thus avoiding radiation injury and contrast medium use, although close surveillance and timely intervention are imperative to ensure long-term patency.
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Affiliation(s)
- Mingxi Lu
- Department of Nephology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.
| | - Hua Li
- Department of Nephology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jian Feng
- Department of Nephology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Weiming Hu
- Department of Nephology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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