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Liao D, Yi X, Bai Y, Yang Y, Ai J. Adeno-associated virus-based gene therapy for cystinuria. BJU Int 2024. [PMID: 38923343 DOI: 10.1111/bju.16451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Dazhou Liao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xianyanling Yi
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yunjin Bai
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Yang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan, China
| | - Jianzhong Ai
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Bhatt NP, Deshpande AV, Starkey MR. Pharmacological interventions for the management of cystinuria: a systematic review. J Nephrol 2024; 37:293-308. [PMID: 37957454 PMCID: PMC11043141 DOI: 10.1007/s40620-023-01795-6] [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: 05/24/2023] [Accepted: 09/26/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Cystinuria is a rare genetic kidney stone disease, with no cure. Current treatments involve lowering urinary cystine levels and increasing cystine solubility. This systematic review evaluates the available literature regarding non-surgical interventions for cystinuria. METHODS Key electronic databases were searched for studies that described the clinical management of cystinuria with high diuresis, alkalinizing agents and thiol-based drugs that were published between 2000 and 2022. Observational studies were included if they contained clinical investigation with at least one previous or current episode of cystine stones, urine cystine levels > 250 mg/L and patients being managed with urinary dilution, alkalinizing agents or other pharmacological agents. All included studies were assessed for study design, patient characteristics and outcomes. A qualitative and critical analysis was performed whereby study quality was assessed using Methodological Index for Non-Randomized Studies (MINORS). Two authors performed the quality assessment and excluded the studies with a low MINORS score. RESULTS Fourteen studies met the review inclusion and quality criteria. Of the fourteen studies, two reported treatment using alkalinizing agents, six reported treatment using thiol-based drugs, and six reported combination treatment using alkalinizing agents and thiol-based drugs. These studies indicated that first-line therapies, including high fluid intake and urinary alkalinization, increased urine volume to > 3 L/day and urinary pH > 7.0, and were associated with reduced urinary cystine levels and cystine stone formation. Second-line therapy with cystine-binding thiol drugs, such as tiopronin and D-penicillamine, reduced urinary cystine levels, cystine crystal volume and increased cystine solubility, resulting in decreased cystine stone formation and stone recurrence rate. Further, combined intervention with alkalinizing agents and thiol-based drugs synergistically reduced stone recurrence. CONCLUSION Cystinuria treatment may require a combined approach of high diuresis, alkalinization and pharmacological interventions with regular monitoring of urinary pH, cystine levels, cystine crystal volume and solubility. However, poor adherence to treatment is relatively frequent, hence the pressing urgency for improved therapies and treatments.
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Affiliation(s)
- Nirmal Prasad Bhatt
- Department of Immunology, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Bladder and Kidney Health Discovery Program, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Aniruddh Vijay Deshpande
- Bladder and Kidney Health Discovery Program, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Australia
- Department of Surgery, Urology Unit, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Malcolm Ronald Starkey
- Department of Immunology, Central Clinical School, Monash University, Melbourne, VIC, Australia.
- Bladder and Kidney Health Discovery Program, Central Clinical School, Monash University, Melbourne, VIC, Australia.
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Mayayo-Vallverdú C, López de Heredia M, Prat E, González L, Espino Guarch M, Vilches C, Muñoz L, Asensi MA, Serra C, Llebaria A, Casado M, Artuch R, Garrabou G, Garcia-Roves PM, Pallardó FV, Nunes V. The antioxidant l-Ergothioneine prevents cystine lithiasis in the Slc7a9 -/- mouse model of cystinuria. Redox Biol 2023; 64:102801. [PMID: 37418888 PMCID: PMC10359938 DOI: 10.1016/j.redox.2023.102801] [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: 05/31/2023] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 07/09/2023] Open
Abstract
The high recurrence rate of cystine lithiasis observed in cystinuria patients highlights the need for new therapeutic options to address this chronic disease. There is growing evidence of an antioxidant defect in cystinuria, which has led to test antioxidant molecules as new therapeutic approaches. In this study, the antioxidant l-Ergothioneine was evaluated, at two different doses, as a preventive and long-term treatment for cystinuria in the Slc7a9-/- mouse model. l-Ergothioneine treatments decreased the rate of stone formation by more than 60% and delayed its onset in those mice that still developed calculi. Although there were no differences in metabolic parameters or urinary cystine concentration between control and treated mice, cystine solubility was increased by 50% in the urines of treated mice. We also demonstrate that l-Ergothioneine needs to be internalized by its transporter OCTN1 (Slc22a4) to be effective, as when administrated to the double mutant Slc7a9-/-Slc22a4-/- mouse model, no effect on the lithiasis phenotype was observed. In kidneys, we detected a decrease in GSH levels and an impairment of maximal mitochondrial respiratory capacity in cystinuric mice that l-Ergothioneine treatment was able to restore. Thus, l-Ergothioneine administration prevented cystine lithiasis in the Slc7a9-/- mouse model by increasing urinary cystine solubility and recovered renal GSH metabolism and mitochondrial function. These results support the need for clinical trials to test l-Ergothioneine as a new treatment for cystinuria.
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Affiliation(s)
- Clara Mayayo-Vallverdú
- Human Molecular Genetics Laboratory, Gene, Disease and Therapy Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain; Genetics Section, Physiological Sciences Department, Health Sciences and Medicine Faculty, University of Barcelona, Barcelona, Spain.
| | - Miguel López de Heredia
- Human Molecular Genetics Laboratory, Gene, Disease and Therapy Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) -CB06/07/0069 - CB06/07/0061 - CB06/07/0073 - CB06/07/1002 - Instituto de Salud Carlos III, Madrid, Spain
| | - Esther Prat
- Human Molecular Genetics Laboratory, Gene, Disease and Therapy Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain; Genetics Section, Physiological Sciences Department, Health Sciences and Medicine Faculty, University of Barcelona, Barcelona, Spain
| | - Laura González
- Human Molecular Genetics Laboratory, Gene, Disease and Therapy Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) -CB06/07/0069 - CB06/07/0061 - CB06/07/0073 - CB06/07/1002 - Instituto de Salud Carlos III, Madrid, Spain
| | - Meritxell Espino Guarch
- Human Molecular Genetics Laboratory, Gene, Disease and Therapy Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain; Immunology Department, Sidra Medicine, Doha, Qatar
| | - Clara Vilches
- Human Molecular Genetics Laboratory, Gene, Disease and Therapy Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain; Institut de Ciències Fotòniques (ICFO), The Barcelona Institute of Science and Technology, 08860, Castelldefels, Barcelona, Spain
| | - Lourdes Muñoz
- SIMChem, Institute for Advanced Chemistry of Catalonia (IQAC-CSIC), Barcelona, Spain
| | - Miguel A Asensi
- Departamento de Fisiología. Universidad de Valencia-INCLIVA, Valencia, Spain
| | - Carmen Serra
- SIMChem, Institute for Advanced Chemistry of Catalonia (IQAC-CSIC), Barcelona, Spain
| | - Amadeu Llebaria
- SIMChem, Institute for Advanced Chemistry of Catalonia (IQAC-CSIC), Barcelona, Spain; MCS, Laboratory of Medicinal Chemistry, Institute for Advanced Chemistry of Catalonia (IQAC-CSIC), Barcelona, Spain
| | - Mercedes Casado
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) -CB06/07/0069 - CB06/07/0061 - CB06/07/0073 - CB06/07/1002 - Instituto de Salud Carlos III, Madrid, Spain; Clinical Biochemistry Department, Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Rafael Artuch
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) -CB06/07/0069 - CB06/07/0061 - CB06/07/0073 - CB06/07/1002 - Instituto de Salud Carlos III, Madrid, Spain; Clinical Biochemistry Department, Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Gloria Garrabou
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) -CB06/07/0069 - CB06/07/0061 - CB06/07/0073 - CB06/07/1002 - Instituto de Salud Carlos III, Madrid, Spain; Muscle Research and Mitochondrial Function Laboratory, Cellex-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Internal Medicine Department-Hospital Clínic of Barcelona, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Pablo M Garcia-Roves
- Department of Physiological Sciences, School of Medicine and Health Sciences, Nutrition, Metabolism and Gene therapy Group Diabetes and Metabolism Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | - Federico V Pallardó
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) -CB06/07/0069 - CB06/07/0061 - CB06/07/0073 - CB06/07/1002 - Instituto de Salud Carlos III, Madrid, Spain; Departamento de Fisiología. Universidad de Valencia-INCLIVA, Valencia, Spain
| | - Virginia Nunes
- Human Molecular Genetics Laboratory, Gene, Disease and Therapy Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Spain; Genetics Section, Physiological Sciences Department, Health Sciences and Medicine Faculty, University of Barcelona, Barcelona, Spain.
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Azer SM, Goldfarb DS. A Summary of Current Guidelines and Future Directions for Medical Management and Monitoring of Patients with Cystinuria. Healthcare (Basel) 2023; 11:healthcare11050674. [PMID: 36900678 PMCID: PMC10000469 DOI: 10.3390/healthcare11050674] [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: 12/04/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023] Open
Abstract
Cystinuria is the most common genetic cause of recurrent kidney stones. As the result of a genetic defect in proximal tubular reabsorption of filtered cystine, increased urine levels of the poorly soluble amino acid result in recurrent cystine nephrolithiasis. Recurrent cystine stones not only adversely affect the quality of patients suffering from cystinuria but also may result in chronic kidney disease (CKD) from recurrent renal injury. Thus, the mainstay of medical management revolves around prevention of stones. Recently published consensus statements on guidelines for managing cystinuria were released from both the United States and Europe. The purpose of this review is to summarize guidelines for medical management of patients with cystinuria, to provide new insight into the utility and clinical significance of cystine capacity-an assay for monitoring cystinuria, and to discuss future directions for research on treatment of cystinuria. We discuss future directions, including the potential use of cystine mimetics, gene therapy, V2-receptor blockers, and SGLT2 inhibitors, topics which have not appeared in more recent reviews. It is notable that in the absence of randomized, controlled trials, the recommendations cited here and in the guidelines are based on our best understanding of the disorder's pathophysiology, observational studies, and clinical experience.
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Affiliation(s)
- Sarah M. Azer
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - David S. Goldfarb
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA
- NYU Langone Medical Center, Nephrology Section, New York Harbor VA Healthcare System, New York, NY 10010, USA
- Correspondence: ; Tel.: +1-212-686-7500 (ext. 3877); Fax: +1-212-951-6842
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D'Ambrosio V, Capolongo G, Goldfarb D, Gambaro G, Ferraro PM. Cystinuria: an update on pathophysiology, genetics, and clinical management. Pediatr Nephrol 2022; 37:1705-1711. [PMID: 34812923 DOI: 10.1007/s00467-021-05342-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/22/2021] [Accepted: 10/12/2021] [Indexed: 11/25/2022]
Abstract
Cystinuria is the most common genetic cause of nephrolithiasis in children. It is considered a heritable aminoaciduria as the genetic defect affects the reabsorption of cystine and three other amino acids (ornithine, lysine, and arginine) in the renal proximal tubule. Patients affected by this condition have elevated excretion of cystine in the urine, and because of this amino acid's low solubility at normal urine pH, patients tend to form cystine calculi. To date, two genes have been identified as disease-causative: SLC3A1 and SLC7A9, encoding for the two subunits of the heterodimeric transporter. The clinical features of this condition are solely related to nephrolithiasis. The diagnosis is usually made during infancy or adolescence, but cases of late diagnosis are common. The goal of therapy is to reduce excretion and increase the solubility of cystine, through both modifications of dietary habits and pharmacological treatment. However, therapeutic interventions are not always sufficient, and patients often have to undergo several surgical procedures during their lives to treat recurrent nephrolithiasis. The goal of this literature review is to synthesize the available evidence on diagnosis and management of patients affected by cystinuria in order to provide physicians with a practical tool that can be used in daily clinical practice. This review also aims to shed some light on new therapy directions with the aim of ameliorating kidney outcomes while improving adherence to treatment and quality of life of cystinuric patients.
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Affiliation(s)
- Viola D'Ambrosio
- Dipartimento Di Scienze Mediche E Chirurgiche, U.O.S. Terapia Conservativa Della Malattia Renale Cronica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, U.O.C. Nefrologia, 00168, Rome, Italy
- Dipartimento Universitario Di Medicina E Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanna Capolongo
- Department of Translational Medical Sciences, Unit of Nephrology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - David Goldfarb
- Nephrology Section, VA, New York Harbor Healthcare System, New York, NY, USA
- Division of Nephrology, New York University Langone Medical Center, New York, NY, USA
| | - Giovanni Gambaro
- Department of Medicine, Division of Nephrology and Dialysis, Renal Unit, University of Verona, Verona, Italy
| | - Pietro Manuel Ferraro
- Dipartimento Di Scienze Mediche E Chirurgiche, U.O.S. Terapia Conservativa Della Malattia Renale Cronica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, U.O.C. Nefrologia, 00168, Rome, Italy.
- Dipartimento Universitario Di Medicina E Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
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Alhasan K, D'Alessandri-Silva C, Mongia A, Topaloglu R, Tasic V, Filler G. Young Adults With Hereditary Tubular Diseases: Practical Aspects for Adult-Focused Colleagues. Adv Chronic Kidney Dis 2022; 29:292-307. [PMID: 36084976 DOI: 10.1053/j.ackd.2021.11.004] [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: 09/21/2021] [Revised: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 11/11/2022]
Abstract
Recent advances in the management of kidney tubular diseases have resulted in a significant cohort of adolescents and young adults transitioning from pediatric- to adult-focused care. Most of the patients under adult-focused care have glomerular diseases, whereas rarer tubular diseases form a considerable proportion of pediatric patients. The purpose of this review is to highlight the clinical signs and symptoms of tubular disorders, as well as their diagnostic workup, including laboratory findings and imaging, during young adulthood. We will then discuss more common disorders such as cystinosis, cystinuria, distal kidney tubular acidosis, congenital nephrogenic diabetes insipidus, Dent disease, rickets, hypercalciuria, and syndromes such as Bartter, Fanconi, Gitelman, Liddle, and Lowe. This review is a practical guide on the diagnostic and therapeutic approach of tubular conditions affecting young adults who are transitioning to adult-focused care.
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Affiliation(s)
- Khalid Alhasan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Cynthia D'Alessandri-Silva
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, and Nephrology, Connecticut Children's Medical Center, Hartford, CT
| | - Anil Mongia
- Department of Pediatrics, SUNY Downstate Medical Center, Brooklyn, NY
| | - Rezan Topaloglu
- Department of Paediatrics, Division of Pediatric Nephrology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Velibor Tasic
- University Children's Hospital, Medical School, Skopje, North Macedonia
| | - Guido Filler
- Department of Paediatrics, Division of Pediatric Nephrology, Western University, London, ON, Canada; Department of Medicine, Western University, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada.
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Kovaříková S, Maršálek P, Vrbová K. Cystinuria in Dogs and Cats: What Do We Know after Almost 200 Years? Animals (Basel) 2021; 11:2437. [PMID: 34438894 PMCID: PMC8388795 DOI: 10.3390/ani11082437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/08/2021] [Accepted: 08/13/2021] [Indexed: 11/18/2022] Open
Abstract
The purpose of this review is to summarize current knowledge on canine and feline cystinuria from available scientific reports. Cystinuria is an inherited metabolic defect characterized by abnormal intestinal and renal amino acid transport in which cystine and the dibasic amino acids ornithine, lysine, and arginine are involved (COLA). At a normal urine pH, ornithine, lysine, and arginine are soluble, but cysteine forms a dimer, cystine, which is relatively insoluble, resulting in crystal precipitation. Mutations in genes coding COLA transporter and the mode of inheritance were identified only in some canine breeds. Cystinuric dogs may form uroliths (mostly in lower urinary tract) which are associated with typical clinical symptoms. The prevalence of cystine urolithiasis is much higher in European countries (up to 14% according to the recent reports) when compared to North America (United States and Canada) where it is approximately 1-3%. Cystinuria may be diagnosed by the detection of cystine urolithiasis, cystine crystalluria, assessment of amino aciduria, or using genetic tests. The management of cystinuria is aimed at urolith removal or dissolution which may be reached by dietary changes or medical treatment. In dogs with androgen-dependent cystinuria, castration will help. In cats, cystinuria occurs less frequently in comparison with dogs.
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Affiliation(s)
- Simona Kovaříková
- Department of Animal Protection and Welfare and Veterinary Public Health, Faculty of Veterinary Hygiene and Ecology, University of Veterinary Sciences, 612 42 Brno, Czech Republic;
| | - Petr Maršálek
- Department of Animal Protection and Welfare and Veterinary Public Health, Faculty of Veterinary Hygiene and Ecology, University of Veterinary Sciences, 612 42 Brno, Czech Republic;
| | - Kateřina Vrbová
- Faculty of Veterinary Medicine, University of Veterinary Sciences, 612 42 Brno, Czech Republic;
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Moussa M, Papatsoris AG, Abou Chakra M, Moussa Y. Update on cystine stones: current and future concepts in treatment. Intractable Rare Dis Res 2020; 9:71-78. [PMID: 32494553 PMCID: PMC7263987 DOI: 10.5582/irdr.2020.03006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cystine stones are relatively uncommon compared with other stone compositions, constituting just 1% to 2% of adult urinary tract stone diseases, and accounting for up to 10% of pediatric stone diseases. Two responsible genes of cystinuria have been identified, the SLC3A1 and the SLC7A9. Cystinuria is diagnosed by family history, stone analysis, or by measurement of urine cystine excretion. Current treatments for cystinuria include increased fluid intake to increase cystine solubility by maintaining daily urine volume of greater than 3 Liter (L). Limiting sodium and protein intake can decrease cystine excretion. When conservative therapy fails, then pharmacologic therapy may be effective. Alkaline urine pH in the 7.0-7.5 range will reduce cystine solubility and can be achieved by the addition of alkali therapy. If these measures fail, cystine-binding thiol drugs such as tiopronin and D-penicillamine are considered. These compounds bind cysteine and prevent the formation of less soluble cystine. These drugs, however, have poor patient compliance due to adverse effects. Captopril can be useful in the treatment of cystine stones but the drug has not been tested in rigorous clinical trials. Novel potential therapies such as alpha-lipoic acid and crystal growth inhibitors (L-cystine dimethyl ester (L-CDME) and L-cystine methyl ester (L-CME)) were developed and tested in animals. Those therapies showed promising results. Compliance with treatment was associated with a lower rate of cystine stone formation.
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Affiliation(s)
- Mohamad Moussa
- Urology Department, Zahraa Hospital, University Medical Center, Lebanese University, Beirut, Lebanon
| | - Athanasios G. Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Mohamad Abou Chakra
- Faculty of Medical Sciences, Department of Urology, Lebanese University, Beirut, Lebanon
- Address correspondence to:Mohamad Abou Chakra, Faculty of Medical Sciences, Department of Urology, Lebanese University. Beirut, Lebanon. E-mail:
| | - Yasmin Moussa
- Clinic of Dermatology, Dr. Brinkmann, Schult & Samimi-Fard. Gladbeck, Germany
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