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Andreoli L, Regola F, Caproli A, Crisafulli F, Fredi M, Lazzaroni MG, Nalli C, Piantoni S, Zatti S, Franceschini F, Tincani A. Pregnancy in antiphospholipid syndrome: what should a rheumatologist know? Rheumatology (Oxford) 2024; 63:SI86-SI95. [PMID: 38320595 DOI: 10.1093/rheumatology/kead537] [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: 07/31/2023] [Accepted: 09/03/2023] [Indexed: 02/08/2024] Open
Abstract
This review focuses on the management of reproductive issues in women who have antiphospholipid syndrome (APS) or are carriers of antiphospholipid antibodies (aPL). The importance of aPL detection during preconception counselling relies on their pathogenic potential for placental insufficiency and related obstetric complications. The risk of adverse pregnancy outcomes can be minimized by individualized risk stratification and tailored treatment aimed at preventing placental insufficiency. Combination therapy of low-dose acetylsalicylic acid and heparin is the mainstay of prophylaxis during pregnancy; immunomodulation, especially with hydroxychloroquine, should be considered in refractory cases. Supplementary ultrasound surveillance is useful to detect fetal growth restriction and correctly tailor the time of delivery. The individual aPL profile must be considered in the stratification of thrombotic risk, such as during assisted reproduction techniques requiring hormonal ovarian stimulation or during the follow-up after pregnancy in order to prevent the first vascular event.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesca Regola
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alessia Caproli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria-Grazia Lazzaroni
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia Nalli
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Silvia Piantoni
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sonia Zatti
- Department of Obstetrics and Gynaecology, ASST Spedali Civili, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit - ERN ReCONNET, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Cheldieva FA, Reshetnyak TM, Shumilova AA, Nurbaeva KS, Cherkasova MV, Lila AM, Nasonov EL. Global Antiphospholipid Syndrome Score (GAPSS) in Patients with Systemic Lupus Erythematosus. DOKL BIOCHEM BIOPHYS 2023; 511:227-234. [PMID: 37833610 PMCID: PMC10739503 DOI: 10.1134/s160767292370028x] [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: 03/27/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 10/15/2023]
Abstract
The Global Antiphospholipid Syndrome Score (GAPSS) is a tool proposed to quantify the risk of clinical manifestations associated with antiphospholipid antibodies (aPL) and certain cardiovascular risk factors. To validate GAPSS in a cohort of patients with systemic lupus erythematosus in Russia. 115 patients with SLE were included in the study, including 51 (44%) patients with systemic lupus erythematosus (SLE) with antiphospholipid syndrome (APS), 14 (12%) SLE patients with aPL, and 50 (44%) patients with SLE. There was a history of thrombosis in 58 (50%) out of 115 patients; of them, 14 (24%) had arterial thrombosis, 29 (50%) had venous thrombosis, and 15 (26%) had combined thrombosis. Pregnancy against the background of the disease occurred in 43 women included in the study. Of them, 29 (67%) had obstetric pathology. Patients with thrombosis and obstetric pathology had a GAPSS score of 7.17 ± 5.64 versus 4.48 ± 4.55 without these manifestations (p = 0.0003). There was a significant association between GAPSS levels and thrombosis: patients with thrombosis had a GAPSS of 7.31 ± 5.70, those without thrombosis-4.00 ± 4.81 (p = 0.001). GAPPS values were higher in arterial thrombosis compared to venous thrombosis (10.40 ± 25.30 versus 5.82 ± 5.28, p = 0.01). GAPSS levels ≥ 6 and ≥10 were analyzed to select GAPSS values at which a high risk of recurrent thrombosis and/or obstetric pathology could be indicated. All GAPSS levels had a significant association with clinical manifestations of APS. The quality of GAPSS by ROC analysis showed an area under the curve (AUC) for GAPSS of 0.697. GAPSS can be used to assess the risk of recurrence or development of thrombosis and/or obstetric pathology in patients with SLE in the Russian Federation. The GAPSS ≥6 values should be used to stratify patients with SLE into high risk group for recurrence of vascular complications. Further prospective follow-up is needed to confirm the value of GAPSS.
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Affiliation(s)
- F A Cheldieva
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia.
| | - T M Reshetnyak
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - A A Shumilova
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - K S Nurbaeva
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - M V Cherkasova
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - A M Lila
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
- Department of Rheumatology, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - E L Nasonov
- Laboratory of Thromboinflammation, Nasonova Research Institute of Rheumatology, Moscow, Russia
- Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Brenner B, Papadakis E, Greer IA, Gris JC. Assessment-based management of placenta-mediated pregnancy complications: Pragmatism until a precision medicine approach evolves. Br J Haematol 2023. [PMID: 37169354 DOI: 10.1111/bjh.18856] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/24/2023] [Accepted: 04/30/2023] [Indexed: 05/13/2023]
Abstract
The management of pregnant women with thrombophilia and a history of gestational vascular complications remains debatable. Treatment of the latter is often based on clinical outcome rather than disease mechanism. While the use of venous thromboembolism prophylaxis in pregnancy is recommended for those at increased risk, the ability of anticoagulant and/or antiplatelet agents to lower the risk of placenta-mediated complications in this clinical setting remains controversial. The available guidelines are inconsistent in some situations, which reflects the limited evidence base. This review critically discusses risk assessment models (RAMs) and management strategies of women with thrombophilia and pregnancy complications, using clinical vignettes. RAMs, taking into account obstetric and thrombotic history as well as thrombophilia status, could drive a precision medicine approach, based on disease mechanism, and guide individual therapeutic interventions in high-risk clinical settings.
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Affiliation(s)
- Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Emmanouil Papadakis
- Thrombosis & Hemostasis Clinic, Ob/Gyn Hematology, Genesis Hospital, Thessaloniki, Greece
| | | | - Jean-Christophe Gris
- Department of Haematology, CHU Nîmes, University of Montpellier, Nîmes, France
- UMR UA11 INSERM IDESP-Montpellier University, Montpellier, France
- Department of Obstetrics, Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Cheldieva FA, Reshetnyak TM, Shumilova AA, Nurbaeva KS, Cherkasova MV, Samarkina EY, Lila AM. Global Antiphospholipid Syndrome Score (GAPSS) in patients with primary antiphospholipid syndrome. MODERN RHEUMATOLOGY JOURNAL 2023. [DOI: 10.14412/1996-7012-2023-1-31-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Stratification of patients into groups of high and low risk of adverse outcome is necessary for timely and early prevention of the disease, as well as the selection of adequate therapy.Objective: to validate the global risk scale for the development of clinical manifestations of antiphospholipid syndrome (GAPSS) in a cohort of patients with primary antiphospholipid syndrome (PAPS).Material and methods. The study included 64 patients with PAPS. Data on clinical manifestations, traditional cardiovascular risk factors, and antiphospholipid antibody profile were collected. GAPSS values were calculated for each patient by summing the scores corresponding to risk factors as follows: 3 points – for hyperlipidemia; 1 point – for arterial hypertension; 5 points – for antibodies to cardiolipin (aCL) IgG/IgM; 4 points – for antibodies to â2-glycoprotein 1 (anti-â2GP1) IgG/IgM and 3 points – for antibodies to the phosphatidylserine-prothrombin complex (aPS/PT) IgG/IgM.Results and discussion. GAPSS indicators were comparable in women and men with PAPS – 12.0 [9.0; 13.0] points. GAPSS values did not differ in patients with thrombosis and obstetric pathology: in thrombosis they were 10.0±4.46 (range 0.0–14.0) points, in obstetric pathology – 9.26±5.08 (range 0.0–14.0) points.The localization of thrombosis did not affect the GAPSS values, which reached 9.23±5.21 points in arterial thrombosis, 10.44±4.01 points in venous thrombosis, and 10.33±4.18 points in combined ones. Patients with recurrent thrombosis had higher GAPSS scores compared to patients without relapse: 8.19±5.25 points versus 11.00±3.65 points (p=0.01). There were no significant differences in GAPSS scores in obstetric pathology at different gestational ages.GAPSS values ≥6 showed a higher risk of thrombosis recurrence: odds ratio 5.23 (95% CI 1.34–20.37). GAPSS scores ≥6 demonstrated the highest accuracy, with sensitivity and specificity of 72% and 66%, respectively. According to ROC analysis, the AUC value for GAPSS was 0.675 (95% CI 0.542–0.808; p=0.01).Conclusion. The use of GAPSS makes it possible to identify patients at increased risk of recurrent thrombosis. GAPSS scores ≥6 have high sensitivity (72%) and specificity (66%), which can be used to stratify patients with PAPS into high and low risk groups for recurrent thrombosis.
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Affiliation(s)
- F. A. Cheldieva
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
| | - T. M. Reshetnyak
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
| | | | - K. S. Nurbaeva
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
| | | | | | - A. M. Lila
- V.A. Nasonova Research Institute of Rheumatology;
Department of Rheumatology Russian Medical Academy of Continuing Professional Education
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Non-Criteria Obstetric Antiphospholipid Syndrome: How Different Is from Sidney Criteria? A Single-Center Study. Biomedicines 2022; 10:biomedicines10112938. [PMID: 36428506 PMCID: PMC9687766 DOI: 10.3390/biomedicines10112938] [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: 10/13/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
This study aims to compare the demographic characteristics, clinical features, serology, and fetal-maternal outcomes between women with obstetric antiphospholipid syndrome (APS) and those with non-criteria (NC)-APS and seronegative (SN)-APS. Two-hundred and sixty-three women with APS obstetric morbidity ever pregnant were included. Of those, 66 met the APS classification criteria, 140 were NC-APS, and 57 were SN-APS. Patients with other autoimmune diseases were excluded. Adverse pregnancy outcomes (APO) included early pregnancy loss, fetal death, preeclampsia, abruptio placentae, and preterm birth. The mean age of the study group was 33.6 ± 5.3 years, and patients were followed up for 129.5 ± 81.9 months. In the NC-APS group, 31 (22.1%) did not fulfill clinical and serological criteria (Subgroup A), 49 (35%) did meet clinical but not serologic criteria (Subgroup B), and 60 (42.9%) fulfilled the serologic criteria but not the clinical ones (Subgroup C). The cardiovascular risk burden was higher in the APS group, due to a higher proportion of smoking. Patients with criteria APS received more intensive treatment than patients in the other study groups. The addition of standard of care (SoC) treatment significantly improved live birth and decreased APO in all groups. Significant clinical differences were observed between the study groups. However, when treated with SoC, fetal-maternal outcomes were similar, with a significant improvement in live births and a decrease in APO. Risk stratification in patients with obstetric morbidity associated with APS can help individualize their treatment.
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Cheldieva FA, Reshetnyak TM, Shumilova AA, Nurbaeva KS, Cherkasova MV, Lila AM, Nasonov EL. Global antiphospholipid syndrome score (GAPSS) in patients with systemic lupus erythematosus. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-546-553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. The Global Antiphospholipid Syndrome Score (GAPSS) is a tool proposed to quantify the risk of clinical manifestations associated with antiphospholipid antibodies (aPL) and certain cardiovascular risk factors.Objective. To validate GAPSS in a cohort of patients with systemic lupus erythematosus in Russia.Material and methods. 115 patients with SLE were included in the study, including 51 (44%) patients with systemic lupus erythematosus (SLE) with antiphospholipid syndrome (APS), 14 (12%) – SLE with aPL, and 50 (44%) – SLE.Results. There was a history of thrombosis in 58 (50%) patients with 115, of them 14 (24%) had arterial thrombosis, 29 (50%) – venous, 15 (26%) – combined. Pregnancy against the background of the disease occurred in 43 women included in the study. Of them, 29 (67%) had obstetric pathology. Patients with thrombosis and obstetric pathology had a GAPSS score of 7.17±5.64, versus 4.48±4.55 without these manifestations (p=0.0003). There was a significant association between GAPSS levels and thrombosis – patients with thrombosis had a GAPSS of 7.31±5.70, those without thrombosis – 4.00±4.81 (p=0.001). GAPPS values were higher in arterial thrombosis compared to venous thrombosis (10.40±25.30 versus 5.82±5.28; p=0.01). GAPSS levels ≥6 and ≥10 were analyzed to select GAPSS values at which a high risk of recurrent thrombosis and/or obstetric pathology could be indicated. All GAPSS levels had a significant association with clinical manifestations of APS. The quality of GAPSS by ROC analysis showed an area under the curve (AUC) for GAPSS of 0.697.Conclusion. GAPSS can be used to assess the risk of recurrence or development of thrombosis and/or obstetric pathology in patients with SLE in the Russian Federation. The GAPSS ≥6 values should be used to stratify patients with SLE into high risk group for recurrence of vascular complications. Further prospective follow-up is needed to confirm the value of GAPSS.
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Affiliation(s)
| | | | | | | | | | - A. M. Lila
- V.A. Nasonova Research Institute of Rheumatology; Russian Medical Academy of Continuous Professional Education
of the Ministry of Healthcare of the Russian Federation
| | - E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; 3
I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
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AliceMSc B, MassimoMD R, IreneMD C, GraziettaMD FS, MartaMD A, ElenaMD R, Elisa M, DarioMD R, Savino S. Assessing the cardiovascular risk in patients with systemic lupus erythematosus: QRISK and GAPSS scores head-to-head. Int J Cardiol 2022; 363:185-189. [PMID: 35714714 DOI: 10.1016/j.ijcard.2022.06.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We aimed to apply and compare the QRISK3 and the adjusted Global AntiPhospholipid Syndrome (APS) Score (aGAPSS) in a cohort of systemic lupus erythematosus (SLE) patients, with and without a concomitant diagnosis of APS, in order to assess their augmented risk of developing cardiovascular diseases (CVDs). METHODS Patients (25-85 yo) with a diagnosis of SLE and/or of Secondary APS (SAPS) were included. QRISK3 was calculated using the official online calculator; aGAPSS using the validated point-values based on aPL-profile and independent risk factors. RESULTS The cohort included 142 SLE patients: 34 SAPS (23.9%) and 108 SLE patients without APS (76.1%).When considering all the cohort, patients with cerebrovascular/coronary events showed higher values of aGAPSS (10.1 ± 6.2 vs. 5.8 ± 6.1; p = 0.007), but not of the QRISK3. Furthermore, a significant association was observed between the occurrence of these events and high-risk aGAPSS: p = 0.03 for aGAPSS≥8, p = 0.01 for aGAPSS ≥9, p = 0.008 for aGAPSS ≥10. aGAPSS strongly correlated with the occurrence of any thrombotic event, both at the uni- and multivariate analysis (p = 0.012 and p = 0.009). Male gender also resulted to positively correlate with the occurrence of any thrombotic event at both uni- and multivariate analysis (p = 0.017 and p = 0.03). Focusing on aPL-profile, regardless the diagnosis, we found a statistical significance only for aGAPSS (aPL+ =9.6 ± 6.3 vs. aPL- = 4.1 ± 5.1; p < 0.001). CONCLUSIONS Despite QRISK3 being more accurate than traditional risk score in predicting CVD risk in SLE patients, aGAPSS appears to be the most valuable tool for this purpose.
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Affiliation(s)
- Barinotti AliceMSc
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Radin MassimoMD
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Cecchi IreneMD
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Foddai Silvia GraziettaMD
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Arbrile MartaMD
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Rubini ElenaMD
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Menegatti Elisa
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Roccatello DarioMD
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy
| | - Sciascia Savino
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy.; University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), San Giovanni Bosco Hub Hospital, and Department of Clinical and Biological Sciences of the University of Turin, Torino, Italy..
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