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Noel S, Kapoor R, Rabb H. New approaches to acute kidney injury. Clin Kidney J 2024; 17:65-81. [PMID: 39583139 PMCID: PMC11581771 DOI: 10.1093/ckj/sfae265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Indexed: 11/26/2024] Open
Abstract
Acute kidney injury (AKI) is a common and serious clinical syndrome that involves complex interplay between different cellular, molecular, metabolic and immunologic mechanisms. Elucidating these pathophysiologic mechanisms is crucial to identify novel biomarkers and therapies. Recent innovative methodologies and the advancement of existing technologies has accelerated our understanding of AKI and led to unexpected new therapeutic candidates. The aim of this review is to introduce and update the reader about recent developments applying novel technologies in omics, imaging, nanomedicine and artificial intelligence to AKI research, plus to provide examples where this can be translated to improve patient care.
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Affiliation(s)
- Sanjeev Noel
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Radhika Kapoor
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Hamid Rabb
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Kapisiz A, Kaya C, Eryilmaz S, Karabulut R, Turkyilmaz Z, Inan MA, Gulbahar O, Sonmez K. Protective effects of lupeol in rats with renal ischemia‑reperfusion injury. Exp Ther Med 2024; 28:313. [PMID: 38911048 PMCID: PMC11190881 DOI: 10.3892/etm.2024.12602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/02/2024] [Indexed: 06/25/2024] Open
Abstract
Acute kidney injury (AKI) caused by ischemia and, exogenous or endogenous nephrotoxic agents poses a serious health issue. AKI is seen in 1% of all hospital admissions, 2-5% of hospitalizations and 67% of intensive care unit (ICU) patients. The in-hospital mortality rates for AKI is 40-50, and >50% for ICU patients. Ischemia-reperfusion (I/R) injury in the kidney can activate inflammatory responses and oxidative stress, resulting in AKI. The common endpoint in acute tubular necrosis is a cellular insult secondary to ischemia or direct toxins, which results in effacement of brush border, cell death and decreased function of tubular cells. The aim of the present study was to assess if the reported antioxidant and anti-inflammatory agent lupeol can exert any effects against renal I/R damage. In total, 24 Wistar Albino rats were randomly assigned into four groups of 6, namely Sham, lupeol, ischemia and therapy groups. In the lupeol group, intraperitoneal administration of 100 mg/kg lupeol was given 1 h before laparotomy, whilst only laparotomy was conducted in the sham group. The renal arteries of both kidneys were clamped for 45 min, 1 h after either intraperitoneal saline injection (in the ischemia group) or 100 mg/kg lupeol application (in the therapy group). The blood samples and renal tissues of all rats were collected after 24 h. In blood samples, blood urea nitrogen (BUN) was measured by the urease enzymatic method, and creatinine was measured by the kinetic Jaffe method. Using ELISA method, TNF-α and IL-6 levels were measured in the blood samples, whereas malondialdehyde (MDA), glutathione (GSH), caspase-3 levels were measured in kidney tissues. In addition, kidney histopathological analysis was performed by evaluating the degree of degeneration, tubular dilatation, interstitial lymphocyte infiltration, protein cylinders, necrosis and loss of brush borders. It was determined that renal damage occurred due to higher BUN, creatinine, MDA, TNF-α and caspase-3 values observed in the kidney tissues and blood samples of rats in ischemia group compared with the Sham group. Compared with those in the ischemia group, rats in the therapy group exhibited increased levels of GSH and reduced levels of BUN, TNF-α, MDA. Furthermore, the ischemia group also had reduced histopathological damage scores. Although differences in creatinine, IL-6 and caspase-3 levels were not statistically significant, they were markedly reduced in the treatment group. Taken together, these findings suggest that lupeol can prevent kidney damage as mainly evidenced by the reduced histopathological damage scores, decreased levels of oxidative stress and reduced levels of inflammatory markers. These properties may allow lupeol to be used in the treatment of AKI.
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Affiliation(s)
- Alparslan Kapisiz
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
| | - Cem Kaya
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
| | - Sibel Eryilmaz
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
| | - Ramazan Karabulut
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
| | - Zafer Turkyilmaz
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
| | - Mehmet Arda Inan
- Department of Pathology, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
| | - Ozlem Gulbahar
- Department of Biochemistry, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
| | - Kaan Sonmez
- Department of Pediatric Surgery, Gazi University Faculty of Medicine, Yenimahalle, 06500 Ankara, Turkey
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Paymannejad S, Dehghani M, Dehkordi RJ, Taheri S, Shamlou F, Salehi H, Kazemi R. Prevalence of acute kidney injury following percutaneous nephrolithotomy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 29:17. [PMID: 38808219 PMCID: PMC11132422 DOI: 10.4103/jrms.jrms_317_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 05/30/2024]
Abstract
Background The objective is to evaluate the prevalence of acute kidney injury (AKI) as an early complication of the percutaneous nephrolithotomy (PCNL) procedure. Materials and Methods From May 2022 to October 2022, we conducted a retrospective study on patients undergoing PCNL procedures in two of the tertiary medical centers affiliated with Isfahan University of Medical Sciences. Patients' baseline characteristics, laboratory values, perioperative data, and stone features were documented. AKI was defined either as a ≥0.3 mg/dL increase in the serum creatinine level within 2 days, or a ≥1.5-fold increase in baseline serum creatinine level within 7 days after the operation. Laboratory values were measured 1 day before PCNL and daily thereafter until discharge. Patients were followed 1 week later to detect all of the possible cases of AKI. Results The final analysis was performed on 347 individuals. AKI developed in 16 (4.61%) cases. The two groups were comparable regarding age (P = 0.887), gender (P = 0.566), and underlying comorbidities including diabetes mellitus (P = 0.577) and hypertension (P = 0.383). The mean body mass index (BMI) (P < 0.001) and both frequency and severity of hydronephrosis (P < 0.001) were significantly different. A higher mean PCNL duration (P < 0.001), period of hospitalization (P < 0.001), and blood loss volume (P < 0.001) were observed in those who developed AKI. Overall, 56.3% (9) of patients in the AKI group and 2.7% (9) in the non-AKI group required the establishment of more than one access tract, during the procedure (P < 0.001). A lower preoperative hemoglobin level was observed in the AKI group (P < 0.001). Those with AKI had significantly larger stones (3.08 ± 0.46 vs. 2.41 ± 0.23 cm, P < 0.001) and higher Hounsfield units (P < 0.001). In addition, in the AKI group, most of the calculi (81.3%, 13) were of staghorn type, whereas in the non-AKI group, calculi were most frequently located in the middle calyx (30.2%, 100), (P < 0.001). Conclusion The prevalence of post-PCNL AKI is approximately 4.61%. The mean BMI, preoperative hemoglobin level, PCNL duration, intraoperative blood loss volume, and hospitalization period were significantly higher among patients who developed AKI. Those with AKI had significantly larger stones with higher Hounsfield units and more frequently of staghorn type. The two groups were not statistically different regarding age, gender, and presence of comorbidities (hypertension and diabetes mellitus).
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Affiliation(s)
- Saina Paymannejad
- Department of Urology, Al-Zahra Institute Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Dehghani
- Department of Urology, Al-Zahra Institute Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Razieh Jafari Dehkordi
- Department of Urology, Al-Zahra Institute Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahram Taheri
- Department of Internal Medicine, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farid Shamlou
- Department of Urology, Al-Zahra Institute Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hanieh Salehi
- Department of Urology, Al-Zahra Institute Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Kazemi
- Department of Urology, Al-Zahra Institute Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Wang F, Lee SY, Adelnia F, Takahashi K, Harkins KD, He L, Zu Z, Ellinger P, Grundmann M, Harris RC, Takahashi T, Gore JC. Severity of polycystic kidney disease revealed by multiparametric MRI. Magn Reson Med 2023; 90:1151-1165. [PMID: 37093746 PMCID: PMC10805116 DOI: 10.1002/mrm.29679] [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: 12/22/2022] [Revised: 03/03/2023] [Accepted: 04/03/2023] [Indexed: 04/25/2023]
Abstract
PURPOSE We aimed to compare multiple MRI parameters, including relaxation rates (R 1 $$ {R}_1 $$ ,R 2 $$ {R}_2 $$ , andR 1 ρ $$ {R}_{1\rho } $$ ), ADC from diffusion weighted imaging, pool size ratio (PSR) from quantitative magnetization transfer, and measures of exchange from spin-lock imaging (S ρ $$ {S}_{\rho } $$ ), for assessing and predicting the severity of polycystic kidney disease (PKD) over time. METHODS Pcy/Pcy mice with CD1 strain, a mouse model of autosomal dominant PKD, were imaged at 5, 9, and 26 wk of age using a 7T MRI system. Twelve-week normal CD1 mice were used as controls. Post-mortem paraffin tissue sections were stained using hematoxylin and eosin and picrosirius red to identify histological changes. RESULTS Histology detected segmental cyst formation in the early stage (week 5) and progression of PKD over time in Pcy kidneys. InT 2 $$ {T}_2 $$ -weighted images, small cysts appeared locally in cystic kidneys in week 5 and gradually extended to the whole cortex and outer stripe of outer medulla region from week 5 to week 26. Regional PSR,R 1 $$ {R}_1 $$ ,R 2 $$ {R}_2 $$ , andR 1 ρ $$ {R}_{1\rho } $$ decreased consistently over time compared to normal kidneys, with significant changes detected in week 5. Among all the MRI measures,R 2 $$ {R}_2 $$ andR 1 ρ $$ {R}_{1\rho } $$ allow highest detectability to PKD, while PSR andR 1 $$ {R}_1 $$ have highest correlation with pathological indices of PKD. Using optimum MRI parameters as regressors, multiple linear regression provides reliable prediction of PKD progression. CONCLUSION R 2 $$ {R}_2 $$ ,R 1 $$ {R}_1 $$ , and PSR are sensitive indicators of the presence of PKD. Multiparametric MRI allows a comprehensive analysis of renal changes caused by cyst formation and expansion.
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Affiliation(s)
- Feng Wang
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center
- Vanderbilt O’Brien Kidney Research Center, Vanderbilt University Medical Center
| | - Seo Yeon Lee
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Fatemeh Adelnia
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center
| | - Keiko Takahashi
- Vanderbilt O’Brien Kidney Research Center, Vanderbilt University Medical Center
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Kevin D. Harkins
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37232
| | - Lilly He
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Zhongliang Zu
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center
| | - Philipp Ellinger
- Bayer AG Research & Development, Pharmaceuticals, 42113 Wuppertal, Germany
| | - Manuel Grundmann
- Bayer AG Research & Development, Pharmaceuticals, 42113 Wuppertal, Germany
| | - Raymond C. Harris
- Vanderbilt O’Brien Kidney Research Center, Vanderbilt University Medical Center
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Takamune Takahashi
- Vanderbilt O’Brien Kidney Research Center, Vanderbilt University Medical Center
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - John C. Gore
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37232
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Chi X, Yang X, Li G, Wu H, Huang J, Qi Y, Tang G. A Comparative Study of 18F-FAPI-42 and 18F-FDG PET/CT for Evaluating Acute Kidney Injury in Cancer Patients. Mol Imaging Biol 2023:10.1007/s11307-023-01820-x. [PMID: 37020127 DOI: 10.1007/s11307-023-01820-x] [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: 01/31/2023] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE Compare the value of imaging using positron 18F-labeled fibroblast activation protein inhibitor-42 (18F-FAPI-42) and 18F-labeled deoxyglucose (18F-FDG) for assessment of AKI. PROCEDURES This study analyzed cancer patients who received 18F-FAPI-42 and 18F-FDG PET/CT imaging. Eight patients had AKI with bilateral ureteral obstruction (BUO), eight had BUO (CKD1-2) with no acute kidney disease (AKD), and eight had no ureteral obstruction (UO) with normal renal function. The average standardized uptake value (SUVave) of the renal parenchyma (RP-SUVave), the blood pool SUVave (B- SUVave), SUVave in the highest region of the renal collective system (RCS-SUVave), and the highest serum creatinine level (top SCr) were recorded. RESULTS The 18F-FAPI-42 and 18F-FDG results showed that radiotracer of renal parenchyma was more concentrated in the AKI group than in the other two groups, whereas the RP-SUVave from 18F-FAPI-42 was higher than that from 18F-FDG in the AKI group (all P < 0.05). 18F-FAPI-42 imaging in the AKI group showed uptake by the renal parenchyma with a diffuse increase, but very little radiotracer in the renal collecting system, similar to a "super kidney scan." The renal parenchyma also had an increase of SUVave, with accumulation of radiotracer in the renal collecting system. AKI was more severe when a patient had a "super kidney scan" in both kidneys (P < 0.05). The B-SUVave level was higher in the AKI group than in the other two groups in 18F-FAPI-42 (both P < 0.05). CONCLUSIONS 18F-FAPI-42 imaging had higher RP-SUVave than 18F-FDG imaging in cancer patients who had BUO with AKI. An increased renal parenchyma uptake in both kidneys and low radiotracer distribution in the collecting system suggest more severe AKI.
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Affiliation(s)
- Xiaohua Chi
- GDMPA Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Xiaoqiang Yang
- GDMPA Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Guiping Li
- GDMPA Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Hubing Wu
- GDMPA Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Jiawen Huang
- GDMPA Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Yongshuai Qi
- GDMPA Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Ganghua Tang
- GDMPA Key Laboratory for Quality Control and Evaluation of Radiopharmaceuticals, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China.
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Zhao P, Li Q, Wang S, Wang Y, Zhu J, Zhu L, Tang J, Luo Y. Quantitative Analysis of Renal Perfusion in Rhabdomyolysis-Induced Acute Kidney Injury Using Contrast-Enhanced Ultrasound: An Experimental Study. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:2110-2118. [PMID: 35914992 DOI: 10.1016/j.ultrasmedbio.2022.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 06/15/2023]
Abstract
The aim of this study was to evaluate renal perfusion changes in rats with acute kidney injury induced by rhabdomyolysis, using quantitative parameters obtained with contrast-enhanced ultrasound (CEUS). Sprague-Dawley (SD) rats were randomly divided into an experimental group (n = 40) and a control group (n = 20). Each group was further divided into four subgroups (0.5-, 6-, 24- and 72-h groups). Time-intensity curves and related quantitative parameters of the renal cortex and medulla were obtained by CEUS, and the contrast characteristics analyzed for different time points. In the experimental group, the CEUS quantitative parameters for the renal medulla of time to peak (TTP), descending time/2 (DT/2) and area under the curve (AUC) increased, whereas ascending slope (AS) and descending slope (DS) decreased. Similarly, renal cortical AS, DS and AUC in the experimental group differed significantly from those in the control group. With respect to the CEUS quantitative parameters for the renal cortex, AUC increased, and AS and DS decreased. These parameters differed significantly between the experimental and control groups. CEUS is sensitive to change in renal perfusion in rhabdomyolysis-induced acute kidney injury and, thus, has diagnostic value.
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Affiliation(s)
- Ping Zhao
- Chinese PLA Medical School, Beijing, China; Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Qiuyang Li
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Shuo Wang
- Chinese PLA Medical School, Beijing, China; Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yiru Wang
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jianing Zhu
- Chinese PLA Medical School, Beijing, China; Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lianhua Zhu
- Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jie Tang
- Chinese PLA Medical School, Beijing, China; Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yukun Luo
- Chinese PLA Medical School, Beijing, China; Department of Ultrasound, First Medical Center, Chinese PLA General Hospital, Beijing, China.
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Morsby JJ, Smith BD. Advances in Optical Sensors of N-Acetyl-β-d-hexosaminidase ( N-Acetyl-β-d-glucosaminidase). Bioconjug Chem 2022; 33:544-554. [PMID: 35302753 PMCID: PMC9870670 DOI: 10.1021/acs.bioconjchem.2c00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
N-Acetyl-β-d-hexosaminidases (EC 3.2.1.52) are exo-acting glycosyl hydrolases that remove N-acetyl-β-d-glucosamine (Glc-NAc) or N-acetyl-β-d-galactosamine (Gal-NAc) from the nonreducing ends of various biomolecules including oligosaccharides, glycoproteins, and glycolipids. The same enzymes are sometimes called N-acetyl-β-d-glucosaminidases, and this review article employs the shorthand descriptor HEX(NAG) to indicate that the terms HEX or NAG are used interchangeably in the literature. The wide distribution of HEX(NAG) throughout the biosphere and its intracellular location in lysosomes combine to make it an important enzyme in food science, agriculture, cell biology, medical diagnostics, and chemotherapy. For more than 50 years, researchers have employed chromogenic derivatives of N-acetyl-β-d-glucosaminide in basic assays for biomedical research and clinical chemistry. Recent conceptual and synthetic innovations in molecular fluorescence sensors, along with concurrent technical improvements in instrumentation, have produced a growing number of new fluorescent imaging and diagnostics methods. A systematic summary of the recent advances in optical sensors for HEX(NAG) is provided under the following headings: assessing kidney health, detection and treatment of infectious disease, fluorescence imaging of cancer, treatment of lysosomal disorders, and reactive probes for chemical biology. The article concludes with some comments on likely future directions.
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Affiliation(s)
| | - Bradley D. Smith
- Corresponding Author: Bradley D. Smith - Department of Chemistry and Biochemistry, 251 Nieuwland Science Hall, University of Notre Dame, IN 46556, USA.
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