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Wang Y, Peng L, Lu X, Zhang H, Zhao H, Zhao T, Yang L, Mao H, Ma F, Liu T, Li P, Zhan Y. Tangshen formula protects against podocyte apoptosis via enhancing the TFEB-mediated autophagy-lysosome pathway in diabetic nephropathy. JOURNAL OF ETHNOPHARMACOLOGY 2024; 324:117721. [PMID: 38199335 DOI: 10.1016/j.jep.2024.117721] [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: 11/21/2023] [Revised: 12/28/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Diabetic nephropathy (DN) is the leading cause of end-stage kidney disease and currently there are no specific and effective drugs for its treatment. Podocyte injury is a detrimental feature and the major cause of albuminuria in DN. We previously reported Tangshen Formula (TSF), a Chinese herbal medicine, has shown therapeutic effects on DN. However, the underlying mechanisms remain obscure. AIM OF THE STUDY This study aimed to explore the protective effect of TSF on podocyte apoptosis in DN and elucidate the potential mechanism. MATERIALS AND METHODS The effects of TSF were assessed in a murine model using male KKAy diabetic mice, as well as in advanced glycation end products-stimulated primary mice podocytes. Transcription factor EB (TFEB) knockdown primary podocytes were employed for mechanistic studies. In vivo and in vitro studies were performed and results assessed using transmission electron microscopy, immunofluorescence staining, and western blotting. RESULTS TSF treatment alleviated podocyte apoptosis and structural impairment, decreased albuminuria, and mitigated renal dysfunction in KKAy mice. Notably, TSF extracted twice showed a more significant reduction in proteinuria than TSF extracted three times. Accumulation of autophagic biomarkers p62 and LC3, and aberrant autophagic flux in podocytes of DN mice were significantly altered by TSF therapy. Consistent with the in vivo results, TSF prevented the apoptosis of primary podocytes exposed to AGEs and activated autophagy. However, the anti-apoptosis capacity of TSF was countered by the autophagy-lysosome inhibitor chloroquine. We found that TSF increased the nuclear translocation of TFEB in diabetic podocytes, and thus upregulated transcription of its several autophagic target genes. Pharmacological activation of TFEB by TSF accelerated the conversion of autophagosome to autolysosome and lysosomal biogenesis, further augmented autophagic flux. Conversely, TFEB knockdown negated the favorable effects of TSF on autophagy in AGEs-stimulated primary podocytes. CONCLUSIONS These findings indicate TSF appears to attenuate podocyte apoptosis and promote autophagy in DN via the TFEB-mediated autophagy-lysosome system. Thus, TSF may be a therapeutic candidate for DN.
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Affiliation(s)
- Yuyang Wang
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Liang Peng
- Beijing Key Laboratory for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Xiaoguang Lu
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Haojun Zhang
- Beijing Key Laboratory for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Hailing Zhao
- Beijing Key Laboratory for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Tingting Zhao
- Beijing Key Laboratory for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Liping Yang
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Huimin Mao
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Fang Ma
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Tongtong Liu
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Ping Li
- Beijing Key Laboratory for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Yongli Zhan
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
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Chhuon C, Herrera-Marcos LV, Zhang SY, Charrière-Bertrand C, Jung V, Lipecka J, Savas B, Nasser N, Pawlak A, Boulmerka H, Audard V, Sahali D, Guerrera IC, Ollero M. Proteomics of Plasma and Plasma-Treated Podocytes: Application to Focal and Segmental Glomerulosclerosis. Int J Mol Sci 2023; 24:12124. [PMID: 37569500 PMCID: PMC10418338 DOI: 10.3390/ijms241512124] [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: 05/16/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Focal and segmental glomerulosclerosis (FSGS) is a severe form of idiopathic nephrotic syndrome (INS), a glomerulopathy of presumably immune origin that is attributed to extrarenal pathogenic circulating factors. The recurrence of FSGS (rFSGS) after transplant occurs in 30% to 50% of cases. The direct analysis of patient plasma proteome has scarcely been addressed to date, mainly due to the methodological difficulties associated with plasma complexity and dynamic range. In this study, first, we compared different methods of plasma preparation, second, we compared the plasma proteomes of rFSGS and controls using two preparation methods, and third, we analyzed the early proximal signaling events in podocytes subjected to patient plasma, through a combination of phosphoproteomics and lipid-raft proteomics (raftomics). By combining immunodepletion and high pH fractionation, we performed a differential proteomic analysis of soluble plasma proteins and of extracellular vesicles (EV) obtained from healthy controls, non-INS patient controls, and rFSGS patients (n = 4). In both the soluble- and the EV-protein sets from the rFSGS patients, we found a statistically significant increase in a cluster of proteins involved in neutrophil degranulation. A group of lipid-binding proteins, generally associated with lipoproteins, was found to be decreased in the soluble set from the rFSGS patients. In addition, three amino acid transporters involved in mTORC1 activation were found to be significantly increased in the EV from the rFSGS. Next, we incubated human podocytes for 30 min with 10% plasma from both groups of patients. The phosphoproteomics and raftomics of the podocytes revealed profound differences in the proteins involved in the mTOR pathway, in autophagy, and in cytoskeleton organization. We analyzed the correlation between the abundance of plasma and plasma-regulated podocyte proteins. The observed changes highlight some of the mechanisms involved in FSGS recurrence and could be used as specific early markers of circulating-factor activity in podocytes.
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Affiliation(s)
- Cerina Chhuon
- Proteomic Platform Necker, Université Paris Cité Structure Fédérative de Recherche SFR Necker US24, 75015 Paris, France; (C.C.); (V.J.); (J.L.)
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - Luis Vicente Herrera-Marcos
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - Shao-Yu Zhang
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - Cécile Charrière-Bertrand
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - Vincent Jung
- Proteomic Platform Necker, Université Paris Cité Structure Fédérative de Recherche SFR Necker US24, 75015 Paris, France; (C.C.); (V.J.); (J.L.)
| | - Joanna Lipecka
- Proteomic Platform Necker, Université Paris Cité Structure Fédérative de Recherche SFR Necker US24, 75015 Paris, France; (C.C.); (V.J.); (J.L.)
| | - Berkan Savas
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - Nour Nasser
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - André Pawlak
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - Hocine Boulmerka
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
| | - Vincent Audard
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
- AP-HP, Hôpitaux Universitaires Henri Mondor, Service de Néphrologie, F-94010 Creteil, France
| | - Dil Sahali
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
- AP-HP, Hôpitaux Universitaires Henri Mondor, Service de Néphrologie, F-94010 Creteil, France
| | - Ida Chiara Guerrera
- Proteomic Platform Necker, Université Paris Cité Structure Fédérative de Recherche SFR Necker US24, 75015 Paris, France; (C.C.); (V.J.); (J.L.)
| | - Mario Ollero
- Univ Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France; (L.V.H.-M.); (S.-Y.Z.); (C.C.-B.); (B.S.); (N.N.); (A.P.); (H.B.); (V.A.); (D.S.)
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Modes of podocyte death in diabetic kidney disease: an update. J Nephrol 2022; 35:1571-1584. [PMID: 35201595 DOI: 10.1007/s40620-022-01269-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/01/2022] [Indexed: 02/06/2023]
Abstract
Diabetic kidney disease (DKD) accounts for a large proportion of end-stage renal diseases that require renal replacement therapies including dialysis and transplantation. Therefore, it is critical to understand the occurrence and development of DKD. Podocytes are mainly injured during the development of DKD, ultimately leading to their extensive death and loss. In turn, the injury and death of glomerular podocytes are also the main culprits of DKD. This review introduces the characteristics of podocytes and summarizes the modes of their death in DKD, including apoptosis, autophagy, mitotic catastrophe (MC), anoikis, necroptosis, and pyroptosis. Apoptosis is characterized by nuclear condensation and the formation of apoptotic bodies, and it exerts a different effect from autophagy in mediating DKD-induced podocyte loss. MC mediates a faulty mitotic process while anoikis separates podocytes from the basement membrane. Moreover, pyroptosis activates inflammatory factors to aggravate podocyte injuries whilst necroptosis drives signaling cascades, such as receptor-interacting protein kinases 1 and 3 and mixed lineage kinase domain-like, ultimately promoting the death of podocytes. In conclusion, a thorough knowledge of the modes of podocyte death in DKD can help us understand the development of DKD and lay the foundation for strategies in DKD disease therapy.
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Huang Q, Fei X, Zhong Z, Zhou J, Gong J, Chen Y, Li Y, Wu X. Stratification of diabetic kidney diseases via data-independent acquisition proteomics-based analysis of human kidney tissue specimens. Front Endocrinol (Lausanne) 2022; 13:995362. [PMID: 36465646 PMCID: PMC9714485 DOI: 10.3389/fendo.2022.995362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
AIM The aims of this study were to analyze the proteomic differences in renal tissues from patients with diabetes mellitus (DM) and diabetic kidney disease (DKD) and to select sensitive biomarkers for early identification of DKD progression. METHODS Pressure cycling technology-pulse data-independent acquisition mass spectrometry was employed to investigate protein alterations in 36 formalin-fixed paraffin-embedded specimens. Then, bioinformatics analysis was performed to identify important signaling pathways and key molecules. Finally, the target proteins were validated in 60 blood and 30 urine samples. RESULTS A total of 52 up- and 311 down-regulated differential proteins were identified as differing among the advanced DKD samples, early DKD samples, and DM controls (adjusted p<0.05). These differentially expressed proteins were mainly involved in ion transport, apoptosis regulation, and the inflammatory response. UniProt database analysis showed that these proteins were mostly enriched in signaling pathways related to metabolism, apoptosis, and inflammation. NBR1 was significantly up-regulated in both early and advanced DKD, with fold changes (FCs) of 175 and 184, respectively (both p<0.01). In addition, VPS37A and ATG4B were significantly down-regulated with DKD progression, with FCs of 0.140 and 0.088, respectively, in advanced DKD and 0.533 and 0.192, respectively, in early DKD compared with the DM control group (both p<0.01). Bioinformatics analysis showed that NBR1, VPS37A, and ATG4B are closely related to autophagy. We also found that serum levels of the three proteins and urine levels of NBR1 decreased with disease progression. Moreover, there was a significant difference in serum VPS37A and ATG4B levels between patients with early and advanced DKD (both p<0.05). The immunohistochemistry assaay exhibited that the three proteins were expressed in renal tubular cells, and NBR1 was also expressed in the cystic wall of renal glomeruli. CONCLUSION The increase in NBR1 expression and the decrease in ATG4B and VPS37 expression in renal tissue are closely related to inhibition of the autophagy pathway, which may contribute to DKD development or progression. These three proteins may serve as sensitive serum biomarkers for early identification of DKD progression.
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Affiliation(s)
- Qinghua Huang
- Department of Endocrinology, Geriatric Medicine Center, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Xianming Fei
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zhaoxian Zhong
- Department of Commerce, Westlake Omics (Hangzhou) Biotechnology Co., Ltd., Hangzhou, Zhejiang, China
| | - Jieru Zhou
- Graduate School, Jinzhou Medical University, Jinzhou, Liaoning, China
| | - Jianguang Gong
- Laboratory of Kidney Disease, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yuan Chen
- Department of Pathology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yiwen Li
- Laboratory of Kidney Disease, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiaohong Wu
- Department of Endocrinology, Geriatric Medicine Center, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- *Correspondence: Xiaohong Wu,
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Audzeyenka I, Bierżyńska A, Lay AC. Podocyte Bioenergetics in the Development of Diabetic Nephropathy: The Role of Mitochondria. Endocrinology 2022; 163:6429716. [PMID: 34791124 PMCID: PMC8660556 DOI: 10.1210/endocr/bqab234] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Indexed: 01/11/2023]
Abstract
Diabetic nephropathy (DN) is the leading cause of kidney failure, with an increasing incidence worldwide. Mitochondrial dysfunction is known to occur in DN and has been implicated in the underlying pathogenesis of disease. These complex organelles have an array of important cellular functions and involvement in signaling pathways, and understanding the intricacies of these responses in health, as well as how they are damaged in disease, is likely to highlight novel therapeutic avenues. A key cell type damaged early in DN is the podocyte, and increasing studies have focused on investigating the role of mitochondria in podocyte injury. This review will summarize what is known about podocyte mitochondrial dynamics in DN, with a particular focus on bioenergetic pathways, highlighting key studies in this field and potential opportunities to target, enhance or protect podocyte mitochondrial function in the treatment of DN.
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Affiliation(s)
- Irena Audzeyenka
- Laboratory of Molecular and Cellular Nephrology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Gdańsk, Poland
- Department of Molecular Biotechnology, Faculty of Chemistry, University of Gdańsk, Gdańsk, Poland
- Correspondence: Irena Audzeyenka, PhD, Laboratory of Molecular and Cellular Nephrology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Wita Stwosza St. 63, 80-308 Gdansk, Poland.
| | - Agnieszka Bierżyńska
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Abigail C Lay
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Cosialls E, El Hage R, Dos Santos L, Gong C, Mehrpour M, Hamaï A. Ferroptosis: Cancer Stem Cells Rely on Iron until "to Die for" It. Cells 2021; 10:cells10112981. [PMID: 34831207 PMCID: PMC8616391 DOI: 10.3390/cells10112981] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 12/13/2022] Open
Abstract
Cancer stem cells (CSCs) are a distinct subpopulation of tumor cells with stem cell-like features. Able to initiate and sustain tumor growth and mostly resistant to anti-cancer therapies, they are thought responsible for tumor recurrence and metastasis. Recent accumulated evidence supports that iron metabolism with the recent discovery of ferroptosis constitutes a promising new lead in the field of anti-CSC therapeutic strategies. Indeed, iron uptake, efflux, storage and regulation pathways are all over-engaged in the tumor microenvironment suggesting that the reprogramming of iron metabolism is a crucial occurrence in tumor cell survival. In particular, recent studies have highlighted the importance of iron metabolism in the maintenance of CSCs. Furthermore, the high concentration of iron found in CSCs, as compared to non-CSCs, underlines their iron addiction. In line with this, if iron is an essential macronutrient that is nevertheless highly reactive, it represents their Achilles’ heel by inducing ferroptosis cell death and therefore providing opportunities to target CSCs. In this review, we first summarize our current understanding of iron metabolism and its regulation in CSCs. Then, we provide an overview of the current knowledge of ferroptosis and discuss the role of autophagy in the (regulation of) ferroptotic pathways. Finally, we discuss the potential therapeutic strategies that could be used for inducing ferroptosis in CSCs to treat cancer.
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Affiliation(s)
- Emma Cosialls
- Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, Université Paris Descartes-Sorbonne Paris Cité, F-75993 Paris, France; (E.C.); (R.E.H.); (L.D.S.)
| | - Rima El Hage
- Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, Université Paris Descartes-Sorbonne Paris Cité, F-75993 Paris, France; (E.C.); (R.E.H.); (L.D.S.)
| | - Leïla Dos Santos
- Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, Université Paris Descartes-Sorbonne Paris Cité, F-75993 Paris, France; (E.C.); (R.E.H.); (L.D.S.)
| | - Chang Gong
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Guangzhou 510120, China;
| | - Maryam Mehrpour
- Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, Université Paris Descartes-Sorbonne Paris Cité, F-75993 Paris, France; (E.C.); (R.E.H.); (L.D.S.)
- Correspondence: (M.M.); (A.H.)
| | - Ahmed Hamaï
- Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, Université Paris Descartes-Sorbonne Paris Cité, F-75993 Paris, France; (E.C.); (R.E.H.); (L.D.S.)
- Correspondence: (M.M.); (A.H.)
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Xue Y, Dongmei Li, Yige Zhang, Hang Gao, Li H. Angelica polysaccharide moderates hypoxia-evoked apoptosis and autophagy in rat neural stem cells by downregulation of BNIP3. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2019; 47:2492-2499. [PMID: 31208217 DOI: 10.1080/21691401.2019.1623228] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Yongzhen Xue
- Department of Children’s Healthcare, East Medical District of Linyi People’s Hospital, Linyi, China
| | - Dongmei Li
- Department of Internal Medicine, Shandong Provincial Coal Linyi Hot Springs Sanatorium Hospital, Linyi, China
| | - Yige Zhang
- Classe Six of Clinical Five-Year System, Medical Department of Qingdao University, Qingdao, China
| | - Hang Gao
- Class eight of Clinical Medicine, Basic Medical College of Jining Medical University, Jining, China
| | - Hui Li
- Department of Children’s Rehabilitation, Linyi Women’s and Children’s Hospital, Linyi, China
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