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Garbelli M, Bellocchio F, Baro Salvador ME, Chermisi M, Rincon Bello A, Godoy IB, Perez SO, Shkolenko K, Perez AS, Toro DS, Apel C, Petrovic J, Stuard S, Barbieri C, Mari F, Neri L. The Use of Anemia Control Model Is Associated with Improved Hemoglobin Target Achievement, Lower Rates of Inappropriate Erythropoietin Stimulating Agents, and Severe Anemia among Dialysis Patients. Blood Purif 2024; 53:405-417. [PMID: 38382484 DOI: 10.1159/000536181] [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: 07/18/2023] [Accepted: 12/29/2023] [Indexed: 02/23/2024]
Abstract
INTRODUCTION The Anemia Control Model (ACM) is a certified medical device suggesting the optimal ESA and iron dosage for patients on hemodialysis. We sought to assess the effectiveness and safety of ACM in a large cohort of hemodialysis patients. METHODS This is a retrospective study of dialysis patients treated in NephroCare centers between June 1, 2013 and December 31, 2019. We compared patients treated according to ACM suggestions and patients treated in clinics where ACM was not activated. We stratified patients belonging to the reference group by historical target achievement rates in their referral centers (tier 1: <70%; tier 2: 70-80%; tier 3: >80%). Groups were matched by propensity score. RESULTS After matching, we obtained four groups with 85,512 patient-months each. ACM had 18% higher target achievement rate, 63% smaller inappropriate ESA administration rate, and 59% smaller severe anemia risk compared to Tier 1 centers (all p < 0.01). The corresponding risk ratios for ACM compared to Tier 2 centers were 1.08 (95% CI: 1.08-1.09), 0.49 (95% CI: 0.47-0.51), and 0.64 (95% CI: 0.61-0.68); for ACM compared to Tier 3 centers, 1.01 (95% CI: 1.01-1.02), 0.66 (95% CI: 0.63-0.69), and 0.94 (95% CI: 0.88-1.00), respectively. ACM was associated with statistically significant reductions in ESA dose administration. CONCLUSION ACM was associated with increased hemoglobin target achievement rate, decreased inappropriate ESA usage and a decreased incidence of severe anemia among patients treated according to ACM suggestion.
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Affiliation(s)
- Mario Garbelli
- Global Medical Office - Clinical Advanced Analytics - Data Science - EMEA, APAC, LATAM region, Fresenius Medical Care Italia spa, Vaiano Cremasco, Italy,
| | - Francesco Bellocchio
- Global Medical Office - Clinical Advanced Analytics - Data Science - EMEA, APAC, LATAM region, Fresenius Medical Care Italia spa, Vaiano Cremasco, Italy
| | | | - Milena Chermisi
- Global Medical Office - Clinical Advanced Analytics - Data Science - EMEA, APAC, LATAM region, Fresenius Medical Care Italia spa, Vaiano Cremasco, Italy
| | - Abraham Rincon Bello
- Country Medical Office - NephroCare Spain, Fresenius Medical Care, Madrid, Spain
| | - Isabel Berdud Godoy
- Country Medical Office - NephroCare Spain, Fresenius Medical Care, Madrid, Spain
| | - Sofia Ortego Perez
- Country Medical Office - NephroCare Spain, Fresenius Medical Care, Madrid, Spain
| | - Kateryna Shkolenko
- Country Medical Office - NephroCare Spain, Fresenius Medical Care, Madrid, Spain
| | - Alicia Sobrino Perez
- Country Medical Office - NephroCare Spain, Fresenius Medical Care, Madrid, Spain
| | - Diana Samaniego Toro
- Country Medical Office - NephroCare Spain, Fresenius Medical Care, Madrid, Spain
| | - Christian Apel
- Health Economics and Market Access, Fresenius Medical Care, Bad Homburg, Germany
| | - Jovana Petrovic
- Health Economics and Market Access, Fresenius Medical Care, Bad Homburg, Germany
| | - Stefano Stuard
- Global Medical Office - Clinical and Therapeutic Governance EMEA, Fresenius Medical Care, Bad Homburg, Germany
| | - Carlo Barbieri
- Global Digital Transformation and Innovation, Clinical Digital Center of Excellence, Fresenius Medical Care, Vaiano Cremasco, Italy
| | - Flavio Mari
- Global Digital Transformation and Innovation, Clinical Digital Center of Excellence, Fresenius Medical Care, Vaiano Cremasco, Italy
| | - Luca Neri
- Global Medical Office - Clinical Advanced Analytics - Data Science - EMEA, APAC, LATAM region, Fresenius Medical Care Italia spa, Vaiano Cremasco, Italy
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Lee WJ, Choi S, Park SM, Lee G, Chang J, Oh YH, Son JS, Kim KH, Choi SJ. Association of hemoglobin variability with the risk of cardiovascular disease: a nationally representative retrospective cohort study from South Korea. Sci Rep 2023; 13:2148. [PMID: 36750725 PMCID: PMC9905090 DOI: 10.1038/s41598-023-28029-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 01/11/2023] [Indexed: 02/09/2023] Open
Abstract
Hemoglobin variability is known to increase cardiovascular mortality in chronic kidney disease, but the association of hemoglobin variability with the risk of cardiovascular disease (CVD) in the general population is yet unclear. This retrospective cohort study based on 'the South Korean National Health Insurance Service database' consisted of 198,347 adults who went through all three health examinations. Hemoglobin variability is defined as the average successive variability of three separate hemoglobin values from each health screening period. Participants were followed up for 6 years to determine the risk of coronary heart disease and stroke. We used multivariate Cox proportional hazards regression to examine the adjusted hazard ratios for CVD according to hemoglobin variability. Per 1 unit increase of hemoglobin variability, the risk for CVD (aHR 1.06, 95% CI 1.02-1.09) and stroke (aHR 1.08, 95% CI 1.03-1.13) increased significantly. The risk-increasing trend was preserved in the low-to-moderate risk group of CVDs (aHR 1.07, 95% CI 1.02-1.11). This result suggests that subjects with high hemoglobin variability who would otherwise be categorized as having low-to-moderate CVD risk may have higher risk of CVD than those with low hemoglobin variability.
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Affiliation(s)
- Won Jung Lee
- Department of Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Seulggie Choi
- Department of Biomedical Sciences, Seoul National University Graduate School, 71 Daehak-Ro, Jongno-Gu, Seoul, South Korea.
| | - Sang Min Park
- Department of Biomedical Sciences, Seoul National University Graduate School, 71 Daehak-Ro, Jongno-Gu, Seoul, South Korea. .,Department of Family Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, South Korea.
| | - Gyeongsil Lee
- Department of Biomedical Sciences, Seoul National University Graduate School, 71 Daehak-Ro, Jongno-Gu, Seoul, South Korea.,Department of Family Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, South Korea
| | - Jooyoung Chang
- Department of Biomedical Sciences, Seoul National University Graduate School, 71 Daehak-Ro, Jongno-Gu, Seoul, South Korea
| | - Yun Hwan Oh
- Department of Family Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong-si, South Korea
| | - Joung Sik Son
- Department of Family Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, South Korea
| | - Kyae Hyung Kim
- Home-Based Medical Care Team, Public Healthcare Center, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, South Korea
| | - Soo Jung Choi
- Department of Family Medicine, Gachon University Gil Medical Center, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, South Korea
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Tao S, Li X, Liu Z, Bai Y, Qian G, Wu H, Li J, Guo Y, Yang S, Chen L, Yang J, Han J, Ma S, Yang J, Yu L, Shui R, Jin X, Wang H, Zhang F, Chen T, Li X, Zong X, Liu L, Fan J, Wang W, Zhang Y, Shi G, Wang D. Investigation on maintenance hemodialysis patients with mineral and bone disorder in Anhui province, China. Int Urol Nephrol 2023; 55:389-398. [PMID: 35951256 DOI: 10.1007/s11255-022-03328-9] [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: 01/16/2022] [Accepted: 07/25/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Chronic kidney disease-mineral bone disorder (CKD-MBD) is a common comorbidity in patients with CKD. The study aims to describe the control rates of serum-corrected calcium (Ca), phosphate (P) and intact parathyroid hormone (iPTH) and its risk factors among maintenance hemodialysis (MHD) patients in Anhui Province of China. METHODS The study was conducted in 27 hemodialysis centers of Anhui Province between January 1st 2020 and December 31th 2020. Chi-square test was used to compare the control rates of serum-corrected Ca, P and iPTH between the present study and DOPPS 4 or Anhui Province in 2014. Binary logistic regression analysis was used to explore the risk factors of the control rates of serum-corrected Ca, P and iPTH. RESULTS A total of 3 025 MHD patients were recruited in this study, with a mean age of 54.8 (SD: 12.8) years, and 60.1% were males. According to the Chinese Diagnosis and Treatment Guidelines for CKD-MBD, the control rates of serum-corrected Ca, P and iPTH in the present study were 57.9%, 20.0% and 56.0%, respectively. Based on KDOQI guidelines (2003), the control rates of the above indicators were 43.1%, 35.3% and 22.3%, respectively. The control rates of serum-corrected Ca, P and iPTH in this study were lower than those of DOPPS 4 (P < 0.001). Compared to the results of Anhui Province in 2014, the control rate of corrected Ca was higher (P < 0.001) and the control rate of iPTH was lower (P = 0.005). Age, residential area, BMI, dialysis vintage, albumin and hemoglobin levels were factors of serum-corrected Ca, P and iPTH not within target range. CONCLUSION The control rates of serum-corrected Ca, P and iPTH in MHD patients in Anhui Province are relatively low. Monitoring and management should be strengthened to improve the prognosis of patients undergoing dialysis.
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Affiliation(s)
- Shuman Tao
- Department of Nephrology, The Second Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, China
| | - Xiuyong Li
- Blood Purification Center, No. 2 People's Hospital of Fuyang City, 1088 Yinghe West Road, Fuyang, 236015, China
| | - Zhi Liu
- Department of Nephrology, The First Affiliated Hospital of Anhui University of Science & Technology, 203 Huaibin Road, Huainan, 232000, China
| | - Youwei Bai
- Department of Nephrology, The Second People's Hospital of Lu'an City, 73 Mozitan Road , Lu'an, 237000, China
| | - Guangrong Qian
- Department of Nephrology, Maanshan People's Hospital, 45 Hubei Road, Maanshan, 243099, China
| | - Han Wu
- Blood Purification Center, Bozhou People's Hospital, 616 Duzhong Road, Bozhou, 236814, China
| | - Ji Li
- Department of Nephrology, Tongling People's Hospital, 468 Bijiashan Road, Tongling, 244099, China
| | - Yuwen Guo
- Department of Nephrology, Lujiang County People's Hospital, 32 Wenmingzhong Road, Lujiang, 231501, China
| | - Shanfei Yang
- Department of Nephrology, Northeast of the Intersection of Binyang Avenue and Dongjin Avenue, Shouxian County Hospital, Shouxian County, 232200, China
| | - Lei Chen
- Department of Nephrology, Hefei Jinnan Kidney Hospital, Northeast of the intersection of Fozhang Road and Beihai Road, Hefei, 230071, China
| | - Jian Yang
- Department of Nephrology, Funan County People's Hospital, 36 Santa Road, Funan County, 236300, China
| | - Jiuhuai Han
- Department of Nephrology, Anqing Municipal Hospital, 87 East Tianzhushan Road, Anqing, 246003, China
| | - Shengyin Ma
- Department of Nephrology, Anhui Wanbei Coal-Electricity Group General Hospital, 125 Huaihe West Road, Suzhou, 234099, China
| | - Jing Yang
- Department of Nephrology, The First People's Hospital of Hefei, 390 Huaihe Road, Hefei, 230061, China
| | - Linfei Yu
- Department of Nephrology, The People's Hospital of Taihu, 196 Renmin Road, Taihu County, 246400, China
| | - Runzhi Shui
- Blood Purification Center, Huangshan City People's Hospital, 4 Liyuan Road, Huangshan, 245000, China
| | - Xiping Jin
- Department of Nephrology, Huainan Chao Yang Hospital, 15 Renmin South Road, Huainan, 232007, China
| | - Hongyu Wang
- Department of Nephrology, Lixin County People's Hospital, Intersection of Wenzhou Road and Feihe Road, Lixin County, 236700, China
| | - Fan Zhang
- Department of Nephrology, Dongzhi County People's Hospital, 70 Jianshe Road, Dongzhi County, 247299, China
| | - Tianhao Chen
- Department of Nephrology, Tianchang City People's Hospital, 137 Jianshe East Road, Tianchang, 239399, China
| | - Xinke Li
- Department of Nephrology, Xiaoxian People's Hospital, 58 Jiankang Road, Xiaoxian County, 235200, China
| | - Xiaoying Zong
- Department of Nephrology, The Second Affiliated Hospital of Bengbu Medical College, 633 Longhua Road, Bengbu, 233017, China
| | - Li Liu
- Department of Nephrology, The Second People's Hospital of Hefei, 246 Heping Road, Hefei, 230012, China
| | - Jihui Fan
- Department of Nephrology, Huaibei People's Hospital, 66 Huaihai West Road, Huaibei, 235000, China
| | - Wei Wang
- Department of Nephrology, The People's Hospital of Xuancheng City, 51 Dabatang Road, Xuancheng, 242099, China
| | - Yong Zhang
- Department of Nephrology, Lujiang County Hospital of TCM, 350 Zhouyu Avenue, Lujiang County, 231501, China
| | - Guangcai Shi
- Department of Nephrology, The Fifth People's Hospital of Hefei, Yuxi Road, Hefei, 230011, China
| | - Deguang Wang
- Department of Nephrology, The Second Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, China.
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Kim DH, Lee YK, Kim J, Park HC, Yun KS, Cho AJ, Yoon JW, Koo JR, Noh JW. Effects of the route of erythropoietin administration on hemoglobin variability and cardiovascular events in hemodialysis patients. Kidney Res Clin Pract 2021; 40:724-733. [PMID: 34510858 PMCID: PMC8685368 DOI: 10.23876/j.krcp.20.260] [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: 12/17/2020] [Accepted: 06/06/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Despite of the routine use of erythropoietin in hemodialysis patients to correct anemia, its administration route's effects on hemoglobin variability and cardiovascular events remain elusive. Herein, we determined different erythropoietin administration routes' effects on hemoglobin variability in hemodialysis patients and the associated factors of hemoglobin variability and cardiovascular events. Methods This is a post hoc analysis of a prospective, controlled, randomized, unblinded study with 78 Korean hemodialysis patients receiving intravenous (n = 40) or subcutaneous (n = 38) erythropoietin therapy. We evaluated hemoglobin variability by calculating the frequency of hemoglobin measurements outside the target range during all visits. The high-frequency group was defined by those with hemoglobin variability over the median value (25%) while the low-frequency group was defined by those with hemoglobin variability of <25%. Results In this analysis, 37 patients (51.1%) were males, and the mean age was 50.6 ± 12.5 years. The frequency of the value being outside the target hemoglobin range was higher in the subcutaneous group compared to the intravenous group (p = 0.03). The low-frequency group required significantly lower erythropoietin doses compared to the high-frequency group. In the adjusted Cox analysis, the parameter high group was a significant independent risk factor for cardiovascular events (p = 0.03). Conclusion The risk out of the target hemoglobin range increased with subcutaneous administration compared with intravenous erythropoietin administration in hemodialysis patients. An increased frequency of the value being outside the target hemoglobin range was also associated with an increased risk of cardiovascular events.
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Affiliation(s)
- Do Hyoung Kim
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea.,Korean Association for the Study of Renal Anemia and Artificial Intelligence, Seoul, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea.,Korean Association for the Study of Renal Anemia and Artificial Intelligence, Seoul, Republic of Korea
| | - Juhee Kim
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Kyu Sang Yun
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - AJin Cho
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jong-Woo Yoon
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ja-Ryong Koo
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jung-Woo Noh
- Department of Internal Medicine, Hallym Kidney Research Institute, Hallym University College of Medicine, Seoul, Republic of Korea
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Kim DH, Oh DJ. Phase angle values, a good indicator of nutritional status, are associated with median value of hemoglobin rather than hemoglobin variability in hemodialysis patients. Ren Fail 2021; 43:327-334. [PMID: 33567950 PMCID: PMC7889140 DOI: 10.1080/0886022x.2020.1870137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Our aim was to elucidate whether Hb variability affects nutritional status in HD patients. Methods This study included chronic HD patients (n = 76) with available monthly Hb levels up to 24 months prior to the body composition monitoring (BCM) measurement. The parameters obtained in the BCM included body mass index (BMI), lean tissue index (LTI), fat tissue index (FTI), body cell mass index (BCMI), overhydration/extracellular water ratio (OH), and phase angle (PhA). The coefficient of variation (Hb-CV), standard deviation (Hb-SD), and range of Hb (Hb-RAN) were used as indexes of Hb variability. In addition, minimum (Hb-Min), maximum (Hb-Max), average (Hb-Avg), and median (Hb-Med) Hb levels (g/dL) were analyzed. Results There were no significant differences in clinical, biochemical, and nutritional indexes based on the Hb-CV level. Compared to patients with an Hb-Med ≤ 10.77, those with an Hb-Med >10.77 had higher albumin levels, total iron-binding capacity (TIBC), and PhA and lower average weekly prescribed darbepoetin. Age, female sex, OH, and darbepoetin dosage were negatively correlated with PhA. Serum albumin, phosphorus, TIBC, Hb-Med, and Hb-Avg were positively correlated with PhA. In multiple linear regression analysis, PhA was positively associated with Hb-Med and serum albumin level, whereas PhA was negatively associated with age and female sex. The area under the curve (AUC) of Hb-Med was 0.665 (p = 0.040) in predicting PhA >5.00° Conclusions PhA was not affected by indexes of Hb variability, whereas PhA was associated with Hb-Med in chronic HD patients.
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Affiliation(s)
- Do Hyoung Kim
- Division of Nephrology, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Dong-Jin Oh
- Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
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Salgado Filho N, Lages JS, Brito DJDA, Santos EJF, dos Santos AM, de Souza FL, Mendes VGG, Silva GADS, Carneiro ECRDL, Muniz MPR, Silva GEB, Sesso RDCC. Variability in Hemoglobin Levels and the Factors Associated with Mortality in Hemodialysis Patients: A 78-Month Follow-Up Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031078. [PMID: 33530448 PMCID: PMC7908351 DOI: 10.3390/ijerph18031078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 12/02/2022]
Abstract
Some studies have described that when the hemoglobin levels of chronic kidney disease (CKD) patients change, especially in those taking erythropoiesis-stimulating agents (ESA), they are associated with unfavorable outcomes such as increased morbidity and mortality, mainly due to cardiovascular events. This prospective cohort study included patients with end-stage renal disease currently undergoing hemodialysis. The initial 6-month clinical evaluation provided data of the variability in hemoglobin, associated blood parameters, and the use of erythropoietin. Subsequently, the patients were followed up for 78 months to evaluate mortality-associated factors. In total, 133 patients completed the 6-month follow-up with a mean age of 47.1 (±13.2) years. The majority were women (51.9%). Six-month hemoglobin levels were as follows: always low (18.0%), intermediate/target (1.5%), always high (0.8%), low-amplitude fluctuation/Hb low (n = 37; 27.8%), low-amplitude fluctuation/Hb high (13.53%), and high-amplitude fluctuation (38.6%), among end-stage renal disease patients. At the end of 78 months, 50 (37.6%) patients died; 70% of deaths were attributed to cardiovascular etiologies. A high variability was observed in hemoglobin levels, which was not associated with mortality. Among all the variables evaluated, age, erythropoietin dose, and transferrin saturation were associated with a higher mortality. Thus, this study suggests that greater attention to erythropoietin doses and transferrin saturation levels may improve the survival of dialysis patients.
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Affiliation(s)
- Natalino Salgado Filho
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
- Correspondence: ; Tel.: +55-98-21091001
| | - Joyce Santos Lages
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Dyego José de Araújo Brito
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Elton John Freitas Santos
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Alcione Miranda dos Santos
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Francival Leite de Souza
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Vinícius Giuliano Gonçalves Mendes
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Giselle Andrade dos Santos Silva
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Erika Cristina Ribeiro de Lima Carneiro
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Monique Pereira Rêgo Muniz
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
| | - Gyl Eanes Barros Silva
- Renal Division, Federal University of Maranhão, São Luís 65020-070, Brazil; (J.S.L.); (D.J.d.A.B.); (E.J.F.S.); (A.M.d.S.); (F.L.d.S.); (V.G.G.M.); (G.A.d.S.S.); (E.C.R.d.L.C.); (M.P.R.M.); (G.E.B.S.)
- Pathology Division, University of São Paulo (USP), Ribeirão Preto 14049-900, Brazil
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