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Ghanbari G, Lam JY, Shashikumar SP, Awdishu L, Singh K, Malhotra A, Nemati S, Yousif Z. Development and validation of a deep learning algorithm for the prediction of serum creatinine in critically ill patients. JAMIA Open 2024; 7:ooae097. [PMID: 39318762 PMCID: PMC11421473 DOI: 10.1093/jamiaopen/ooae097] [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: 07/14/2024] [Revised: 09/01/2024] [Accepted: 09/08/2024] [Indexed: 09/26/2024] Open
Abstract
Objectives Serum creatinine (SCr) is the primary biomarker for assessing kidney function; however, it may lag behind true kidney function, especially in instances of acute kidney injury (AKI). The objective of the work is to develop Nephrocast, a deep-learning model to predict next-day SCr in adult patients treated in the intensive care unit (ICU). Materials and Methods Nephrocast was trained and validated, temporally and prospectively, using electronic health record data of adult patients admitted to the ICU in the University of California San Diego Health (UCSDH) between January 1, 2016 and June 22, 2024. The model features consisted of demographics, comorbidities, vital signs and laboratory measurements, and medications. Model performance was evaluated by mean absolute error (MAE) and root-mean-square error (RMSE) and compared against the prediction day's SCr as a reference. Results A total of 28 191 encounters met the eligibility criteria, corresponding to 105 718 patient-days. The median (interquartile range [IQR]) MAE and RMSE in the internal test set were 0.09 (0.085-0.09) mg/dL and 0.15 (0.146-0.152) mg/dL, respectively. In the prospective validation, the MAE and RMSE were 0.09 mg/dL and 0.14 mg/dL, respectively. The model's performance was superior to the reference SCr. Discussion and Conclusion Our model demonstrated good performance in predicting next-day SCr by leveraging clinical data routinely collected in the ICU. The model could aid clinicians in in identifying high-risk patients for AKI, predicting AKI trajectory, and informing the dosing of renally eliminated drugs.
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Affiliation(s)
- Ghodsieh Ghanbari
- Department of Biomedical Informatics, University of California San Diego (UCSD) School of Medicine, La Jolla, CA 92093, United States
| | - Jonathan Y Lam
- Department of Biomedical Informatics, University of California San Diego (UCSD) School of Medicine, La Jolla, CA 92093, United States
| | - Supreeth P Shashikumar
- Department of Biomedical Informatics, University of California San Diego (UCSD) School of Medicine, La Jolla, CA 92093, United States
| | - Linda Awdishu
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UCSD, La Jolla, CA 92093, United States
| | - Karandeep Singh
- Joan and Irwin Jacobs Center for Health Innovation, UC San Diego Health, San Diego, CA 92093, United States
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, UCSD, La Jolla, CA 92093, United States
| | - Shamim Nemati
- Department of Biomedical Informatics, University of California San Diego (UCSD) School of Medicine, La Jolla, CA 92093, United States
| | - Zaid Yousif
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UCSD, La Jolla, CA 92093, United States
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Yousif ZK, Koola JD, Macedo E, Cerda J, Goldstein SL, Chakravarthi R, Lewington A, Selewski D, Zappitelli M, Cruz D, Tolwani A, Joy MS, Jha V, Ramachandran R, Ostermann M, Pandya B, Acharya A, Brophy P, Ponce D, Steinke J, Bouchard J, Irarrazabal CE, Irarrazabal R, Boltansky A, Askenazi D, Kolhe N, Claure-Del Granado R, Benador N, Castledine C, Davenport A, Barratt J, Bhandari S, Riley AA, Davis T, Farmer C, Hogarth M, Thomas M, Murray PT, Robinson-Cohen C, Nicoletti P, Vaingankar S, Mehta R, Awdishu L. Clinical Characteristics and Outcomes of Drug-Induced Acute Kidney Injury Cases. Kidney Int Rep 2023; 8:2333-2344. [PMID: 38025217 PMCID: PMC10658426 DOI: 10.1016/j.ekir.2023.07.037] [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: 01/27/2023] [Revised: 06/22/2023] [Accepted: 07/31/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Drug-induced acute kidney injury (DI-AKI) is a frequent adverse event. The identification of DI-AKI is challenged by competing etiologies, clinical heterogeneity among patients, and a lack of accurate diagnostic tools. Our research aims to describe the clinical characteristics and predictive variables of DI-AKI. Methods We analyzed data from the Drug-Induced Renal Injury Consortium (DIRECT) study (NCT02159209), an international, multicenter, observational cohort study of enriched clinically adjudicated DI-AKI cases. Cases met the primary inclusion criteria if the patient was exposed to at least 1 nephrotoxic drug for a minimum of 24 hours prior to AKI onset. Cases were clinically adjudicated, and inter-rater reliability (IRR) was measured using Krippendorff's alpha. Variables associated with DI-AKI were identified using L1 regularized multivariable logistic regression. Model performance was assessed using the area under the receiver operating characteristic curve (ROC AUC). Results A total of 314 AKI cases met the eligibility criteria for this analysis, and 271 (86%) cases were adjudicated as DI-AKI. The majority of the AKI cases were recruited from the United States (68%). The most frequent causal nephrotoxic drugs were vancomycin (48.7%), nonsteroidal antiinflammatory drugs (18.2%), and piperacillin/tazobactam (17.8%). The IRR for DI-AKI adjudication was 0.309. The multivariable model identified age, vascular capacity, hyperglycemia, infections, pyuria, serum creatinine (SCr) trends, and contrast media as significant predictors of DI-AKI with good performance (ROC AUC 0.86). Conclusion The identification of DI-AKI is challenging even with comprehensive adjudication by experienced nephrologists. Our analysis identified key clinical characteristics and outcomes of DI-AKI compared to other AKI etiologies.
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Affiliation(s)
- Zaid K. Yousif
- Division of Clinical Pharmacy, University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical, La Jolla, California, USA
| | - Jejo D. Koola
- Division of Biomedical Informatics, Department of Medicine, University of California, La Jolla, California, USA
- Division of Hospital Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jorge Cerda
- Albany Medical College, Albany, New York, USA
- St. Peter's Hospital Partners, Albany, New York, USA
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | | | - David Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Dinna Cruz
- Division of Nephrology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | | | - Melanie S. Joy
- University of Colorado School of Pharmacy and Pharmaceutical Sciences and School of Medicine in Aurora, Colorado, USA
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, MManipal Academy of Higher Education, Manipal, India
| | - Raja Ramachandran
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King’s College London, Guy’s and St Thomas’ Hospital, London, UK
| | - Bhavna Pandya
- Medical and Dental Staff Governor, Liverpool University Hospitals NHS Foundation Trust/Aintree University Hospital, Liverpool, UK
| | - Anjali Acharya
- Jacobi Medical Center, Albert Einstein College of Medicine, The Bronx, New York, New York, USA
| | - Patrick Brophy
- Department of Pediatrics at the University of Rochester School of Medicine and Dentistry, New York, USA
| | | | - Julia Steinke
- Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Josee Bouchard
- Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Carlos E. Irarrazabal
- Programa de Fisiología, Centro de Investigación e Innovación Biomédica, Universidad de los Andes, Santiago, Chile
| | | | | | - David Askenazi
- Children's of Alabama (UAB-Pediatrics), Birmingham, Alabama, USA
| | - Nitin Kolhe
- Consultant Nephrologist, Royal Derby Hospital, Derby, UK
| | - Rolando Claure-Del Granado
- Division of Nephrology Hospital Obrero No 2 – CNS Cochabamba, Bolivia/Universidad Mayor de San Simón School of Medicine Cochabamba, Bolivia
| | - Nadine Benador
- University of California San Diego, San Diego, California, USA / Rady Children's Hospital, San Diego, USA
| | | | - Andrew Davenport
- University College London, Department of Renal Medicine, Royal Free London NHS Trust London, UK
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Alyssa A. Riley
- Department of Pediatrics, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - T.K. Davis
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Christopher Farmer
- Centre for Health Services Studies, George Allen Wing, Cornwallis Building, University of Kent, Canterbury, Kent, UK
| | - Michael Hogarth
- Division of Biomedical Informatics, Department of Medicine, University of California, La Jolla, California, USA
| | - Mark Thomas
- Birmingham Heartlands Hospital, Birmingham, Alabama, USA
| | | | - Cassianne Robinson-Cohen
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Tennessee, USA
| | - Paola Nicoletti
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Ravindra Mehta
- Division of Nephrology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Linda Awdishu
- Division of Clinical Pharmacy, University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical, La Jolla, California, USA
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Dobrek L. A Synopsis of Current Theories on Drug-Induced Nephrotoxicity. Life (Basel) 2023; 13:life13020325. [PMID: 36836682 PMCID: PMC9960203 DOI: 10.3390/life13020325] [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: 11/28/2022] [Revised: 01/11/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
The overriding goal of the treatment of patients is its effectiveness and safety. However, all medications currently being used also exert some adverse pharmaceutical reactions, which may be regarded as an unintended but inevitable cost of pharmacotherapy. The kidney, as the main organ that eliminates xenobiotics, is an organ especially predisposed and vulnerable to the toxic effects of drugs and their metabolites during their excretion from the body. Moreover, some drugs (e.g., aminoglycosides, cyclosporin A, cisplatin, amphotericin B, and others) have a "preferential" nephrotoxicity potential, and their use is associated with an increased risk of kidney damage. Drug nephrotoxicity is, therefore, both a significant problem and a complication of pharmacotherapy. It should be noted that, currently, there is no generally recognized definition of drug-induced nephrotoxicity and no clear criteria for its diagnosis. This review briefly describes the epidemiology and diagnosis of drug-induced nephrotoxicity and characterizes its pathomechanisms, including immunological and inflammatory disturbances, altered kidney blood flow, tubulointerstitial injury, increased lithogenesis-crystal nephropathy, rhabdomyolysis, and thrombotic microangiopathy. The study also lists the basic drugs with nephrotoxicity potential and provides a short overview of the preventive methods for reducing the risk of drug-related kidney damage developing.
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Affiliation(s)
- Lukasz Dobrek
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
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4
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Figueiredo AC, Nunes I, Ferreira E, Faria E. Rare case of interstitial nephritis in a young adult under IgG therapy. BMJ Case Rep 2022; 15:e246651. [PMID: 35110283 PMCID: PMC8811552 DOI: 10.1136/bcr-2021-246651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/04/2022] Open
Abstract
Immunoglobulin replacement therapy is an important therapeutic approach used in different diseases, such as immunodeficiency diseases. We report a case of a 19-year-old female patient with suspected common variable immunodeficiency who started replacement therapy with IgG. During the follow-up, she developed interstitial nephritis and the subsequent workup excluded other diseases or triggers except IgG therapy.
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Affiliation(s)
- Ana Carolina Figueiredo
- Nephrology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- Clínica Universitária de Nefrologia, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Inês Nunes
- Allergy and Clinical Immunology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Emanuel Ferreira
- Nephrology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- Clínica Universitária de Nefrologia, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Emilia Faria
- Allergy and Clinical Immunology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
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Badar A, Ahmed A, Al-Tamimi DM, Isab AA, Altaf M, Ahmed S. Histological Changes in Renal, Hepatic and Cardiac Tissues of Wistar Rats after 6 Weeks Treatment with Bipyridine Gold (III) Complex with Dithiocarbamate Ligands. Pharmaceutics 2021; 13:pharmaceutics13101530. [PMID: 34683832 PMCID: PMC8539664 DOI: 10.3390/pharmaceutics13101530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022] Open
Abstract
Bipyridine gold (III) dithiocarbamate compounds are Gold-III complexes with promising cytotoxic properties. In this study, the subacute toxicity of a Gold (III) complex with dithiocarbamate ligand was evaluated. In the acute toxicity component, an initial LD50 (38.46 mg/kg) was calculated by the administration of 50, 100, 200, 400, and 800 mg/kg of the compound to five groups of rats, respectively (n = 4 each). The sixth group was the control. The sub-acute toxicity component comprised the control group A (n = 6) and the study groups B (n = 10) and C (n = 4), which were administered 1 mL distilled water, 1/10 LD50 (3.8 mg/kg), and 1/5 LD50 (7.6 mg/kg), respectively, daily for 6 weeks. The alive animals were then sacrificed. Autopsy; preservation of renal, hepatic and cardiac tissue in buffered formalin; histopathological processing; microscopic evaluation; and comparison with the controls were sequentially conducted. In the subacute toxicity study at dosages of 3.8 mg/kg and 7.6 mg/kg, the renal tubules remained unaffected with no necrosis or vacuolization. Mild to moderate renal interstitial, hepatic capsular, lobular and portal inflammation along with mild focal hepatic vacuolization were present. At 3.8 mg/kg, the cardiac muscle fibers were unremarkable in 80% (n = 8) of the specimens, with mild focal hyalinization in 20% (n = 2) of the specimens. The same was observed in 50% (n = 2) of the specimens at 7.6 mg/kg. Variable congestion was evident in all of the groups. In the subacute toxicity study, the absence of renal tubular necrosis or vacuolization, the presence of mild inflammatory hepatic and renal alterations, and predominantly unremarkable cardiac muscle fibers suggest that Bipyridine gold (III)-dithiocarbamate is safe in animal studies and is a potential candidate for clinical trials.
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Affiliation(s)
- Ahmed Badar
- Department of Physiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia
- Correspondence:
| | - Ayesha Ahmed
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia; (A.A.); (D.M.A.-T.)
| | - Dalal M. Al-Tamimi
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia; (A.A.); (D.M.A.-T.)
| | - Anvarhusein A. Isab
- Department of Chemistry, King Fahd University of Petroleum and Minerals, Dhahran 31261, Saudi Arabia;
| | - Muhammad Altaf
- Department of Chemistry, Government College University, Lahore 54000, Pakistan;
| | - Sania Ahmed
- Army Medical College, Abid Majeed Road, Rawalpindi 46000, Pakistan;
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Fields SD, Tung E. Patient-Focused Selection of PrEP Medication for Individuals at Risk of HIV: A Narrative Review. Infect Dis Ther 2021; 10:165-186. [PMID: 33569743 PMCID: PMC7875561 DOI: 10.1007/s40121-020-00384-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/23/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP) medication is a key component of the HIV prevention strategy in the US, which has been demonstrated to be highly effective in preventing HIV acquisition among individuals at risk. Two PrEP medications are currently approved: emtricitabine/tenofovir disoproxil fumarate (Truvada®; F/TDF) was approved by the US Food and Drug Administration in 2012, followed by emtricitabine/tenofovir alafenamide (Descovy®; F/TAF) in 2019. An ongoing randomized, double-blind, Phase 3 study (DISCOVER) demonstrated that F/TAF had non-inferior efficacy to F/TDF. While both medications have been found to be efficacious and well tolerated, several studies have identified that important differences exist with regards to pharmacokinetics, bone and renal safety profiles, and other factors. In this narrative review, we conducted a comprehensive evaluation of the populations at risk of HIV who may also be affected by, or at risk of, bone or renal conditions. We reviewed the safety profiles of F/TDF and F/TAF to develop an evidence-based algorithm for selecting the appropriate PrEP medication, based on biological, behavioral, and health characteristics of an individual at risk of HIV, and considered how the choice of PrEP medication may or may not compound safety concerns for these individuals. We identified that the introduction of F/TAF provides a valuable alternative to F/TDF, allowing the personalization of PrEP. F/TAF may be the preferred medication for cisgender men and transgender women at risk of HIV infection who are predisposed to, or already have, bone or renal conditions. While the approval of F/TAF is the first step in personalization of PrEP, additional options are still warranted to help accommodate the wide spectrum of individuals at risk of HIV with different lifestyles, medical histories, preferences, and requirements.
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Affiliation(s)
- Sheldon D Fields
- The Pennsylvania State University, College of Nursing, University Park, PA, USA.
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7
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Soveri I, Helmersson-Karlqvist J, Fellström B, Larsson A. Day-to-day variation of the kidney proximal tubular injury markers urinary cystatin C, KIM1, and NGAL in patients with chronic kidney disease. Ren Fail 2021; 42:400-404. [PMID: 32349578 PMCID: PMC7241568 DOI: 10.1080/0886022x.2020.1757463] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: It is important to know the intraindividual variation of biomarkers to be able to distinguish a change of a biomarker due to the course of the disease from the normal biological variation of the marker. The purpose of this study was to investigate the day-to-day variability of urine markers in nephrology patients.Materials: 23 nephrology patients were included in the study. First morning urine samples were collected daily for ten consecutive days and analyzed for U-cystatin C, U-KIM1, U-NGAL and U-creatinine. The day-to-day variation was calculated as concentrations of the markers and as creatinine ratios. Values deviating more than the 90th percentile of the normal intraindividual variation was used to define a disease/treatment specific change.Results: The day-to-day coefficient of variation (CV) for individual patients varied between 9.6 and 100.3% for NGAL (mean 45.6%) and between 8.8 and 107.3% for the NGAL/creatinine ratio (mean 43.8%). The corresponding values for KIM1 were between 10.9 and 60.2% (mean 30.1%) and for the ratio between 8.7 and 59.8% (mean 23.4%) and for cystatin C 3.8-67.4% (mean 25.0%) and for the cystatin C/creatinine ratio 5.9-78.4% (mean 24.8%).Conclusions: The similar intraindividual CV values between the renal tubules damage markers and their corresponding creatinine ratios speaks against using creatinine ratio. Using the 90th percentiles of the CV values as a limit for clinical change means that NGAL has to change by 83.3%, KIM1 by 45.5% and Cystatin C by 46.3% before the change can be considered clinically significant in patients with chronic kidney disease.
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Affiliation(s)
- Inga Soveri
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | | | - Bengt Fellström
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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8
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Sri Laasya T, Thakur S, Poduri R, Joshi G. Current insights toward kidney injury: Decrypting the dual role and mechanism involved of herbal drugs in inducing kidney injury and its treatment. CURRENT RESEARCH IN BIOTECHNOLOGY 2020. [DOI: 10.1016/j.crbiot.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Abstract
PURPOSE OF REVIEW Renovascular disease (RVD) remains an important cause of hypertension and renal dysfunction. Given the failure of renal revascularization to provide consistent clinical benefit in the Cardiovascular Outcomes for Renal Artery Lesions trial among others, further research has underscored the need for mechanistically targeted interventions to improve renal outcomes in patients in RVD. This review discusses novel therapeutic approaches for RVD in the post-Cardiovascular Outcomes for Renal Artery Lesions era. RECENT FINDINGS Emerging evidence indicates that renal inflammation, microvascular remodeling, and mitochondrial damage accelerate progression of renal injury and are important determinants of the response to revascularization. Experimental studies have identified interventions capable of ameliorating renal inflammation (e.g., cytokine inhibitors, mesenchymal stem cells), microvascular remodeling (proangiogenic interventions), and mitochondrial injury (mito-protective drugs), alone or combined with renal revascularization, to preserve the structure and function of the poststenotic kidney. Recent prospective pilot studies in patients with atherosclerotic RVD demonstrate the safety and feasibility of some of such interventions to protect the kidney. SUMMARY Experimental studies and pilot clinical trials suggest that therapies targeting renal inflammation, microvascular remodeling, and mitochondrial damage have the potential to preserve the structure and function of the stenotic kidney. Further studies in larger cohorts are needed to confirm their renoprotective effects and clinical role in human RVD.
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Downes KJ, Hayes M, Fitzgerald JC, Pais GM, Liu J, Zane NR, Goldstein SL, Scheetz MH, Zuppa AF. Mechanisms of antimicrobial-induced nephrotoxicity in children. J Antimicrob Chemother 2020; 75:1-13. [PMID: 31369087 PMCID: PMC6910165 DOI: 10.1093/jac/dkz325] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Drug-induced nephrotoxicity is responsible for 20% to 60% of cases of acute kidney injury in hospitalized patients and is associated with increased morbidity and mortality in both children and adults. Antimicrobials are one of the most common classes of medications prescribed globally and also among the most common causes of nephrotoxicity. A broad range of antimicrobial agents have been associated with nephrotoxicity, but the features of kidney injury vary based on the agent, its mechanism of injury and the site of toxicity within the kidney. Distinguishing nephrotoxicity caused by an antimicrobial agent from other potential inciting factors is important to facilitate both early recognition of drug toxicity and prompt cessation of an offending drug, as well as to avoid unnecessary discontinuation of an innocuous therapy. This review will detail the different types of antimicrobial-induced nephrotoxicity: acute tubular necrosis, acute interstitial nephritis and obstructive nephropathy. It will also describe the mechanism of injury caused by specific antimicrobial agents and classes (vancomycin, aminoglycosides, polymyxins, antivirals, amphotericin B), highlight the toxicodynamics of these drugs and provide guidance on administration or monitoring practices that can mitigate toxicity, when known. Particular attention will be paid to paediatric patients, when applicable, in whom nephrotoxin exposure is an often-underappreciated cause of kidney injury.
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Affiliation(s)
- Kevin J Downes
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Molly Hayes
- Antimicrobial Stewardship Program, Center for Healthcare Quality & Analytics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie C Fitzgerald
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Jiajun Liu
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
- Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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11
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Chen W, Yuan H, Cao W, Wang T, Chen W, Yu H, Fu Y, Jiang B, Zhou H, Guo H, Zhao X. Blocking interleukin-6 trans-signaling protects against renal fibrosis by suppressing STAT3 activation. Am J Cancer Res 2019; 9:3980-3991. [PMID: 31281526 PMCID: PMC6592178 DOI: 10.7150/thno.32352] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/09/2019] [Indexed: 01/04/2023] Open
Abstract
Rationale: Renal fibrosis is the terminal manifestation of chronic and irreversible renal disease. Effective therapies other than dialysis are extremely limited. In this study, we investigated the potential effects of targeting elevated interleukin-6 (IL-6) levels in the treatment of renal fibrosis. Methods: Fc-gp130 was used to specifically block IL-6 trans-signaling. Unilateral ureteral occlusion (UUO) and ischemia reperfusion (IR) mouse models were constructed to investigate the therapeutic effect of Fc-gp130 on renal fibrosis. The role of IL-6 trans-signaling and phosphorylation of signal transducer and activator of transcription (STAT) 3 in regulating fibroblast accumulation and extracellular matrix protein deposition were evaluated in cell experiments and mouse models. Results: The kidneys of mice with UUO were found to have elevated soluble IL-6 receptor (sIL-6R) levels in the progression of fibrosis. Fc-gp130 attenuated renal fibrosis in mice, as evidenced by reductions in tubular atrophy and the production of extracellular matrix protein. Blockade of IL-6 trans-signaling with Fc-gp130 also reduced inflammation levels, immune cell infiltration, and profibrotic cytokines expression in renal tissue, with decreased STAT3 phosphorylation and reduced fibroblast accumulation in the renal tissue. In vitro, Fc-gp130 also reduced the phosphorylation of STAT3 induced by transforming growth factor (TGF)-β1 in fibroblasts. Furthermore, the therapeutic effect of Fc-gp130 was confirmed in a model of acute kidney injury-chronic kidney disease. Conclusion: Overall, IL-6 trans-signaling may contribute to crucial events in the development of renal fibrosis, and the targeting of IL-6 trans-signaling by Fc-gp130 may provide a novel therapeutic strategy for the treatment of renal fibrosis.
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Cheng M, Gu X, Turbat-Herrera EA, Herrera GA. Tubular Injury and Dendritic Cell Activation Are Integral Components of Light Chain-Associated Acute Tubulointerstitial Nephritis. Arch Pathol Lab Med 2019; 143:1212-1224. [PMID: 31063013 DOI: 10.5858/arpa.2018-0032-oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Light chain-associated acute tubulointerstitial nephritis (LC-ATIN) is a variant of light chain proximal tubulopathy (LCPT). It is characterized by interstitial inflammation with tubulitis and deposition of monoclonal light chains in the tubulointerstitium. LC-ATIN is a rather poorly recognized pattern of LCPT and not much is known about this entity. OBJECTIVE.— To determine the clinicopathologic features of patients with LC-ATIN and investigate the proximal tubular injury and mechanism of interstitial inflammation in LC-ATIN. DESIGN.— A total of 38 cases of LC-ATIN were identified from the archives of 5043 renal biopsy specimens. In all cases, routine light microscopic examination, immunofluorescence, and electron microscopic examination were performed. In selected cases, immunofluorescent staining of dendritic cells and immunohistochemical staining for 4 tubular injury markers-KIM-1, p53, bcl-2, and Ki-67-were performed. RESULTS.— A characteristic finding in LC-ATIN cases was immunofluorescence staining of monoclonal light chains along tubular basement membranes in linear fashion and inside proximal tubular cells with a granular pattern. No monoclonal light chains were present in glomerular or vascular compartments confirmed with immunofluorescence, electron microscopy, and ultrastructural gold labeling. Ten of 15 LC-ATIN cases (67%) were concurrently positive for the 4 tubular injury markers. Dendritic cells were identified within the tubulointerstitium in the renal biopsy specimens, interacting with surrounding tubules with light-chain deposits and inflammatory cells. CONCLUSIONS.— Significant proximal tubular injury occurs associated with LC-ATIN, and the monoclonal light chains accumulated in proximal tubular cells contribute to the injury. Dendritic cells are involved in the pathogenesis of interstitial inflammation in LC-ATIN.
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Affiliation(s)
- Mingyu Cheng
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
| | - Xin Gu
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
| | - Elba A Turbat-Herrera
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
| | - Guillermo A Herrera
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
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Nastase MV, Zeng-Brouwers J, Wygrecka M, Schaefer L. Targeting renal fibrosis: Mechanisms and drug delivery systems. Adv Drug Deliv Rev 2018; 129:295-307. [PMID: 29288033 DOI: 10.1016/j.addr.2017.12.019] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/10/2017] [Accepted: 12/22/2017] [Indexed: 12/21/2022]
Abstract
Renal fibrosis is the common outcome of many chronic kidney diseases (CKD) independent of the underlying etiology. Despite a host of promising experimental data, currently available strategies only ameliorate or delay the progression of CKD but do not reverse fibrosis. One of the major impediments of translating novel antifibrotic strategies from bench to bedside is due to the intricacies of the drug delivery process. In this review, we briefly describe mechanisms of renal fibrosis and methods of drug transfer into the kidney. Various tools used in gene therapy to administer nucleic acids in vivo are discussed. Furthermore, we review the modes of action of protein- or peptide-based drugs with target-specific antibodies and cytokines incorporated in hydrogels. Additionally, we assess an intriguing new method to deliver drugs specifically to tubular epithelial cells via conjugation with ligands binding to the megalin receptor. Finally, plant-derived compounds with antifibrotic properties are also summarized.
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Affiliation(s)
- Madalina V Nastase
- Pharmazentrum Frankfurt/ZAFES, Institut für Allgemeine Pharmakologie und Toxikologie, Klinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; National Institute for Chemical-Pharmaceutical Research and Development, 112 Vitan Avenue, 031299 Bucharest, Romania
| | - Jinyang Zeng-Brouwers
- Pharmazentrum Frankfurt/ZAFES, Institut für Allgemeine Pharmakologie und Toxikologie, Klinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Malgorzata Wygrecka
- Department of Biochemistry, Faculty of Medicine, Universities of Giessen and Marburg Lung Center, Friedrichstrasse 24, 35392 Giessen, Germany.
| | - Liliana Schaefer
- Pharmazentrum Frankfurt/ZAFES, Institut für Allgemeine Pharmakologie und Toxikologie, Klinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.
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14
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Theron AJ, Anderson R, Rossouw TM, Steel HC. The Role of Transforming Growth Factor Beta-1 in the Progression of HIV/AIDS and Development of Non-AIDS-Defining Fibrotic Disorders. Front Immunol 2017; 8:1461. [PMID: 29163528 PMCID: PMC5673850 DOI: 10.3389/fimmu.2017.01461] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/18/2017] [Indexed: 12/21/2022] Open
Abstract
Even after attainment of sustained viral suppression following implementation of highly active antiretroviral therapy, HIV-infected persons continue to experience persistent, low-grade, systemic inflammation. Among other mechanisms, this appears to result from ongoing microbial translocation from a damaged gastrointestinal tract. This HIV-related chronic inflammatory response is paralleled by counteracting, but only partially effective, biological anti-inflammatory processes. Paradoxically, however, this anti-inflammatory response not only exacerbates immunosuppression but also predisposes for development of non-AIDS-related, non-communicable disorders. With respect to the pathogenesis of both sustained immunosuppression and the increased frequency of non-AIDS-related disorders, the anti-inflammatory/profibrotic cytokine, transforming growth factor-β1 (TGF-β1), which remains persistently elevated in both untreated and virally suppressed HIV-infected persons, may provide a common link. In this context, the current review is focused on two different, albeit related, harmful activities of TGF-β1 in HIV infection. First, on the spectrum of anti-inflammatory/immunosuppressive activities of TGF-β1 and the involvement of this cytokine, derived predominantly from T regulatory cells, in driving disease progression in HIV-infected persons via both non-fibrotic and profibrotic mechanisms. Second, the possible involvement of sustained elevations in circulating and tissue TGF-β1 in the pathogenesis of non-AIDS-defining cardiovascular, hepatic, pulmonary and renal disorders, together with a brief comment on potential TGF-β1-targeted therapeutic strategies.
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Affiliation(s)
- Annette J. Theron
- Faculty of Health Sciences, Department of Immunology, Institute for Cellular and Molecular Medicine, University of Pretoria, Pretoria, South Africa
- Tshwane Academic Division of the National Health Laboratory Service, Pretoria, South Africa
| | - Ronald Anderson
- Faculty of Health Sciences, Department of Immunology, Institute for Cellular and Molecular Medicine, University of Pretoria, Pretoria, South Africa
| | - Theresa M. Rossouw
- Faculty of Health Sciences, Department of Immunology, Institute for Cellular and Molecular Medicine, University of Pretoria, Pretoria, South Africa
| | - Helen C. Steel
- Faculty of Health Sciences, Department of Immunology, Institute for Cellular and Molecular Medicine, University of Pretoria, Pretoria, South Africa
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Tang H, Li D, Zhang J, Li Y, Wang T, Zhai S, Song Y. Sodium-glucose co-transporter-2 inhibitors and risk of adverse renal outcomes among patients with type 2 diabetes: A network and cumulative meta-analysis of randomized controlled trials. Diabetes Obes Metab 2017; 19:1106-1115. [PMID: 28240446 DOI: 10.1111/dom.12917] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/11/2017] [Accepted: 02/16/2017] [Indexed: 02/06/2023]
Abstract
AIM To compare the associations of individual sodium-glucose co-transporter-2 (SGLT2) inhibitors with adverse renal outcomes in patients with type 2 diabetes mellitus (T2DM). METHODS PubMed, EMBASE, CENTRAL and ClinicalTrials.gov were searched for studies published up to May 24, 2016, without language or date restrictions. Randomized trials that reported at least 1 renal-related adverse outcome in patients with T2DM treated with SGLT2 inhibitors were included. Pairwise and network meta-analyses were carried out to calculate the odds ratios (ORs) with 95% confidence intervals (CIs), and a cumulative meta-analysis was performed to assess the robustness of evidence. RESULTS In total, we extracted 1334 composite renal events among 39 741 patients from 58 trials, and 511 acute renal impairment/failure events among 36 716 patients from 53 trials. Dapagliflozin was significantly associated with a greater risk of composite renal events than placebo (OR 1.64, 95% CI 1.26-2.13). Empagliflozin seemed to confer a lower risk than placebo (OR 0.63, 95% CI 0.54-0.72), canagliflozin (OR 0.48, 95% CI 0.29-0.82) and dapagliflozin (OR 0.38, 95% CI 0.28-0.51). With regard to acute renal impairment/failure, only empagliflozin was significantly associated with a lower risk than placebo (OR 0.72, 95% CI 0.60-0.86). The cumulative meta-analysis indicated the robustness of our significant findings. CONCLUSIONS The present meta-analysis indicated that dapagliflozin may increase the risk of adverse renal events, while empagliflozin may have a protective effect among patients with T2DM. Further data from large well-conducted randomized controlled trials and a real-world setting are warranted.
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Affiliation(s)
- Huilin Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
- Center for Pharmacoepidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jingjing Zhang
- Division of Nephrology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yufeng Li
- Department of Endocrinology, Beijing Pinggu Hospital, Beijing, China
| | - Tiansheng Wang
- Department of Pharmacy Administration and Clinical Pharmacy, Peking University Health Science Center, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Yiqing Song
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
- Center for Pharmacoepidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
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Nast CC. Medication-Induced Interstitial Nephritis in the 21st Century. Adv Chronic Kidney Dis 2017; 24:72-79. [PMID: 28284382 DOI: 10.1053/j.ackd.2016.11.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/21/2016] [Accepted: 11/21/2016] [Indexed: 01/19/2023]
Abstract
Interstitial nephritis is an immune mediated form of tubulointerstitial kidney injury that may occur secondary to drugs, autoimmune disease, infections, and hematologic disorders or as a reactive process. Drug-induced acute interstitial nephritis (DI-AIN) occurs in 0.5%-3% of all kidney biopsies and in 5%-27% of biopsies performed for acute kidney injury. Drugs are implicated in 70%-90% of biopsy-proved IN with a prevalence of 50% in less developed to 78% in more developed countries. DI-AIN typically is idiosyncratic because of a delayed hypersensitivity reaction, although some chemotherapeutic agents are permissive for immune upregulation and injure the kidney in a dose-related manner. Antibiotics are the most implicated class of medication in DI-AIN, followed by proton pump inhibitors, nonsteroidal anti-inflammatory agents, and 5-aminosalicylates. Diuretics, allopurinol, phenytoin and other anti-seizure medications, and H2 receptor antagonists are known offenders while chemotherapeutic agents are an under-recognized cause. The symptoms of DI-AIN are variable and often not specific; thus, kidney biopsy is required to make a firm diagnosis. The incidence of DI-AIN appears to be increasing, particularly in the elderly in whom kidney biopsy is underused, and identification of the offending agent may be complicated by polypharmacy. As rapid drug discontinuation may improve prognosis, the possibility of DI-AIN should always be considered in a patient with acute kidney injury.
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Eirin A. Hitching a ride to renal repair. Am J Physiol Renal Physiol 2017; 312:F276-F277. [DOI: 10.1152/ajprenal.00589.2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/07/2016] [Indexed: 11/22/2022] Open
Affiliation(s)
- Alfonso Eirin
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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